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For members who are taking drugs that are either not on Health Net's Medicare Part D Formulary or are subject to restrictions or limitations.
Under Health Net's transition program, members are given access to non-formulary drugs. This includes Part D drugs that are not on the Health Net Medicare Part D formulary, as well as drugs that are on the formulary with a limit or restriction (not based on safety).
The transition program is designed to ensure continuity of care for new members, existing members who may be subject to formulary changes, and members who experience a level of care change. The program also allows members in long-term care facilities access to a temporary transition supply of drugs.
If you are a new member, you may be taking drugs that are not on the formulary or you may be taking drugs that are on the formulary but have restrictions or limits. For example, you may need a prior authorization from us before your prescription can be filled. In these cases, you should talk to your doctor or other prescriber to decide if you should change to drugs that we cover or request an exception so we will cover the drugs you take. While you talk to your doctor or other prescriber to determine the right course of action for you, we may cover your drugs in certain cases during the first 90 days you are a member of our plan. We will cover a one-time temporary 30-day transition supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If your prescription is written for less than a 30-day transition supply, refills for up to a total of a 30-day supply will be covered. This may also apply if you are a renewing member and experience a change in the formulary at the beginning of the contract year.
If you are a new member and are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will allow you to refill your prescription until we have provided you with a 102-day transition supply (unless you have a prescription written for fewer days).
If you are a resident of a long-term care facility and past the first 90 days of membership in our plan and you need drugs that are not on the formulary or are on the formulary with certain limits or restrictions (not based on safety), we will cover up to a 34-day emergency supply of your drugs (unless you have a prescription written for fewer days) while you seek an exception. If your prescription is written for less than a 34-day transition supply, refills for up to a total of a 34-day supply will be covered.
Level of Care Changes
If you experience a change in level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility.
We understand that there are other circumstances when an override may be granted. These situations are managed on a case-by-case basis through communication between the dispensing pharmacy and Health Net.
You will be sent a transition letter to notify you that Health Net has covered a transition supply of your drug because the drug is not on the Health Net Medicare Part D formulary, or to notify you that your drug is is on the formulary but is subject to restrictions or limits.
The transition letter is member specific and is available for free in another format or language upon request. To request this document in another format or language, please call Customer Service.
Information last updated 10/09/2012