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Transition Policy

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

  • The drug you have been taking is no longer on the plan’s Drug List.

  • -- or -- the drug you have been taking is now restricted in some way (Chapter 5, Section 4 of the Evidence of Coverager tells about restrictions).

2. You must be in one of the situations described below:

  • For those members who are new or who were in the plan last year and aren’t in a long-term care (LTC) facility:
    We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. The prescription must be filled at a network pharmacy.

  • For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
    We will cover a temporary supply of your drug during the first 90 days ofyour membership in the plan if you are new and during the first 90 daysof the calendar yearif you were in the plan last year. The total supply will be for a maximum of 93 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 93 days of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

  • For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
    We will cover one 31 day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

  • If you experience a change in your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a one-time temporary supply for up to 30 days (or 31 days if you are a long-term care resident) from a network pharmacy. During this period, you should use the plan’s exception process if you wish to have continued coverage of the drug after the temporary supply is finished.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options.

 

Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

H1659_Web2018 Approved 10112017
Last Updated: 01/02/2018