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Prescription medication transition policy

Prescription medication transition policy

Bright Health wants to make getting Medicare Part D coverage for the treatment you need as seamless as possible. The policy applies to new members taking a medication that is not covered, members entering/discharging from a long-term care facility, or current members who are impacted by a formulary change. Designed to give members an opportunity to work with their doctors to complete a successful transition and avoid disruption in treatment, the policy ensures coverage for a temporary supply of medication.

How the policy works

The Transition Policy provides at least a one-time, temporary 30-day fill, anytime during the first 90 days of your enrollment in the plan, beginning on your effective date of coverage.

We encourage members to talk with their doctors to decide if they should switch to a different drug that is covered or to request a formulary exception to get coverage for the drug.

If you live in a long-term care facility, the transition process will provide for a maximum single fill 31-day supply, which you may refill until you have received at least a 91 to 98 day transition supply during the first 90 days of your enrollment in the plan, beginning on your effective date of coverage.

After the transition period has expired or the days supply is exhausted, the transition policy will provide members living in a long-term care facility at least a 31-day emergency supply of non-formulary Part D drugs (unless the beneficiary presents with a prescription written for less than the 31 days) while an exception or prior authorization determination is pending.

For members being admitted to, or discharged from, a long term care facility, the early refill edits will not be used to limit appropriate and necessary access to their Part D benefit, and such enrollees will be allowed to access a refill upon admission or discharge.

We will provide you with written notice within three business days of your temporary transition supply that will include instructions for requesting a formulary exception and how to work with your doctor to decide if you should switch to an appropriate drug we cover.

The transition policy applies to Part D drugs that (a) are not on the plan’s formulary; (b) were previously approved for coverage under an exception once the exception expires, and (c) that are on the plan’s formulary but require prior authorization or step therapy, or that have approved quantity limits lower than the beneficiary’s current dose, under the plan’s utilization management rules.

All prescriptions must be filled at an in-network pharmacy.