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Drug Transition Policy

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Drug Transition Policy

If a drug that you take is not on our List of Drugs (Formulary) or is restricted, here are things you can do:

  • You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your doctor or other prescriber time to change to another drug or to file a request to have the drug covered.
  • You can change to another drug.
  • You can request an exception and ask us to cover the drug or remove restrictions from the drug.

In certain situations and following the Centers for Medicare and Medicaid Services (CMS) requirements, we can offer you a temporary supply of your drug. A temporary supply helps your immediate need. It also gives you time to talk with your doctor about a different dose or another drug that we do cover, or to complete an exception request.

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

1. The drug that you take:

  • Is no longer on our list of drugs, or
  • Was never on our list of drugs, or
  • Is now restricted in some way

(Chapter 5 in your Evidence of Coverage has more information).

AND

2. You are in one of these situations:

You are new to the plan:

  • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply at a retail pharmacy, or a 31-day supply at a long-term care pharmacy. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication at a retail pharmacy, and a 31-day supply of medication at a long-term care pharmacy. The prescription must be filled at a network pharmacy. (Please note, the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

You were in the plan last year:

  • We will cover a temporary supply of your drug 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 a 30-day supply at retail pharmacy, or a 31-day supply at a long-term care pharmacy. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication at a retail pharmacy, and a 31-day supply of medication at a long-term care pharmacy. The prescription must be filled at a network pharmacy. (Please note, the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

You have been a member for more than 90 days, you are in a long-term care facility, and you need a supply right away:

  • We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care supply. When your prescription is filled you and your doctor should request an exception or prior authorization.

Additionally, based on your required level of care, the place where you get and take your drugs (your treatment setting) could change. This could be, but is not limited to, if you:

  • Are discharged from a hospital or a skilled nursing facility to a home setting, or
  • Are admitted to a hospital or a skilled nursing facility from a home setting, or
  • End your skilled nursing facility (Medicare Part A) stay, where payments include all pharmacy charges, and you need to use your Part D plan benefit, or
  • Give up hospice status and go back to standard Medicare Part A and B coverage, or
  • Are discharged from a psychiatric hospital with a highly individualized drug regimen.

For these treatment setting changes, we will cover as much as a 30-31-day temporary supply of a Part D-covered drug when filled at a network pharmacy.

If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization for continued coverage of your drug. We review continuation of therapy requests on a case-by-case basis if you are on a stabilized drug regimen that, if changed, is known to have risks.

There are other situations where you may receive a temporary supply. To ask for a temporary supply of a drug, contact Member Services.

After you get your Temporary Supply

Within three business days after you receive your temporary supply, you and your doctor will receive a letter explaining what to do next. You should talk with your doctor to decide what to do when your supply runs out. You can:

  • Change to another drug. We may have other drugs that might work for you. You can contact Member Services to ask for a list of covered drugs. Share the list with your doctor to decide if there is an alternate drug that would be just as effective for your condition.
  • Ask for an exception. You or your doctor can ask us to make an exception or submit a request for coverage determination. For example, you can ask us to cover a drug even though it is not on our list of drugs. Or, you can ask us to cover the drug without limits.

H0562_19_11585EGWEB_C_03142019

Information last updated 03-14-2019

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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