Pharmacy Plan Coverage

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you’re a member of our plan.

NEW MEMBERS TO HEALTHTEAM ADVANTAGE

(Including new enrollees in HealthTeam Advantage following the annual coordinated election period, newly eligible Medicare beneficiaries from other coverage or members who switch from one plan to another after the start of a contract year):

Within the first 90 days of coverage with HealthTeam Advantage starting from your effective date of coverage, we will provide new members a temporary 30-day fill (unless you present a prescription written for less than 30 days, in which case we’ll allow multiple fills to provide up to a total of 30 days of medication) of non-formulary medication or medications that require step therapy, prior authorization, or are subject to quantity limit restrictions (unless the prescription is written for fewer days). If the smallest available package size is more than a 30-day supply, a transition supply for an appropriate day supply greater than 30 will be provided.

LONG TERM CARE (LTC) FACILITY RESIDENTS:

Within the first 90 days of coverage with HealthTeam Advantage starting from your effective date of coverage, new HealthTeam Advantage members residing in a Long Term Care (LTC) facility will be provided a one-time temporary fill of at least a month’s supply (unless the prescription is written for less) and multiple fills may be provided if needed of non-formulary medications or medications requiring prior authorization, step therapy or are subject to quantity limit restrictions. If the smallest available package size exceeds the 31-day supply, a transition supply for an appropriate day’s supply exceeding 31 days will be provided.

If you’re new to the LTC setting or currently in the LTC setting and your 90-day transition period has expired, HealthTeam Advantage will provide a 31-day emergency supply of non-formulary Part D drugs or medications that are on our formulary but require prior authorization, step therapy, or quantity limit restrictions under our utilization management rules (unless the prescription presented is written for less than 31 days) while an exception or prior authorization is being processed. Additionally, if you’re admitted or discharged from an LTC facility, you’ll have access to early refills, if necessary. If the smallest available package size exceeds the 31-day supply, a transition supply for an appropriate day’s supply exceeding 31 will be provided.

Transition across plan years

Because the list of covered formulary medications is subject to change from year to year, we have a transition policy for current HealthTeam Advantage members who are taking a medication that won’t be covered in the new plan year or medications that will have step therapy, prior authorization, or quantity limit restrictions in the new plan year. In the first 90 days of the new plan year, HealthTeam Advantage will provide a temporary 30-day supply (unless you present a prescription written for less than 30 days, in which case we will allow multiple fills to provide up to a total of 30 days of medication) of the requested non-formulary prescription drug (or drug that has new step therapy, prior authorization requirements, or quantity limit restrictions) when you’ve had a prescription for the medication filled within the past 120 days of the date of the attempted fill. In addition, members who were granted an exception in the previous plan year will have that exception continued provide there is a paid claim for the medication in the past 120 days.

EMERGENCY TRANSITIONS AND LEVEL OF CARE CHANGES

You may have a change in your treatment setting due to the level of care you require. Such transitions include:

• If you’re discharged from a hospital or skilled nursing facility to a home setting
• If you’re admitted to a hospital or skilled nursing facility from a home setting
• If you transfer from one skilled nursing facility to another and that new facility is serviced by a different pharmacy
• If you end your skilled nursing facility Medicare Part A stay—where payments include all pharmacy charges— and you now need to use your Part D plan benefit
• If you give up Hospice status and revert back to standard Medicare Part A and B coverage

If you’re outside your transition period, and experience a level of care change, HealthTeam Advantage will allow you access to a 30/31 day refill (30 days in the retail setting and 31 days in the long-term care (LTC) setting) for formulary medications and an emergency 30/31 day (30 days in the retail setting and 31 days in the LTC setting) transition fill for non-formulary medications (including Part D drugs that are on the Plan’s formulary but require prior authorization, step therapy exception or quantity limit exception). This will occur on a case-by-case basis when an exception request or appeal has been filed but has not been completed by the end of the transition period. All transition fills for new members, either in the retail setting or LTC setting, will process automatically. If you require a transition fill outside of your first 90 days with HealthTeam Advantage, you or your pharmacist should contact RxAdvance (see phone numbers below), 7 days a week, 24 hours a day (TTY/TDD users should call 711), so we can implement our transition policy for you. If you enroll in our plan while living at home and then become a resident of an LTC facility, please call RxAdvance (see phone numbers below) to let us know you’re now a resident of an LTC facility. We can then implement an LTC transition policy for you. This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from LTC or hospital facilities.

We’ll send you written notice via U.S. first-class mail within three business days of receiving your transition fill transaction from the pharmacy. This will contain an explanation of the temporary nature of that prescription fill, instructions on how to identify an appropriate therapeutic alternative that is on our formulary, an explanation of your right to request a formulary exception, and the procedure for requesting a formulary exception.

HealthTeam Advantage Plan I and Plan II PPO members call RxAdvance at 1-800-237-1992 (TTY:711)

HealthTeam  Advantage Diabetes & Heart Care HMO members call RxAdvance at 1-800-459-0984 (TTY:711)