Transitions

What if my current prescription drugs are not on the formulary or are limited on the formulary?

2010 Transition Policy

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 that 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 are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug.

For example, members who:

1. Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours).
2. Are discharged from a hospital to a home.
3. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
4. End a long-term care facility stay and return to the community.

If a member has more than one change in level of care in a month, the pharmacy will have to call our Plan to request an extension of the transition policy.

For more detailed information about your CCHP SelectCare (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about CCHP SelectCare (HMO), please call Pharmacy Services at 877-661-6230 (Press 3), Monday through Sunday, 8:00 AM - 8:00 PM. TTY/TDD California Relay users should call 800-735-2929.