Plan Transition Process
For medications with special requirements
Transition Support to Meet Your Needs
As a new Elixir Insurance plan member you may be taking medications that are not on our drug list (also called a formulary) or medications that are on our formulary but require prior authorization, step therapy, or quantity limit restrictions.
If you are taking a medication that is not on our formulary or is on the formulary but requires step therapy, you should ask your doctor to determine if there is an appropriate formulary medication that can be substituted. If your doctor determines that there is no formulary medication that can be substituted for your current therapy, you may request a formulary exception (a request for coverage of a non-formulary medication, step therapy exception, or a quantity limit exception).
If you are on a medication that requires prior authorization, we require documentation that you meet the criteria for coverage of the medication.
While you and your doctor are determining the right course of action for you, we have the following policy in place to ensure that you are not left without medication coverage:
- New Members to the Elixir Insurance plan (new enrollees into the plan following the annual coordinated election period, newly eligible Medicare beneficiaries from other coverage at the beginning of a contract year or enrollees who switch from one plan to another after the beginning of a contract year.)
Within the first 90 days of coverage with Elixir Insurance starting from your effective date of coverage, we will provide new enrollees a temporary 30-day fill (unless you present a prescription written for less than 30 days in which case we will allow multiple fills to provide up to a total of 30 days of medication) of non-formulary medication or medications that require Step Therapy, Prior Authorization, or are subject to Quantity Limit restrictions.
- Long Term Care (LTC) Members
Within the first 90 days of coverage with Elixir Insurance starting from your effective date of coverage, new Elixir Insurance enrollees residing in a Long Term Care (LTC) facility will be provided a temporary supply of non-formulary medications or medications requiring prior authorization, step therapy or are subject to quantity limit restrictions. The temporary supply will be for up to 31 days (unless you present a prescription written for less than 31 days in which case we will allow multiple fills to provide up to a total of 31 days of medication). If you are new to the Long Term Care setting or currently in the Long Term Care Setting and your 90-day transition period has expired, we will provide you with a 31-day emergency supply of non-formulary Part D drugs or medications that are on our formulary but require prior authorization, step therapy, or quantity limit restrictions under our utilization management rules (unless the prescription presented is written for less than 31 days) while an exception or prior authorization is being processed. Additionally, if you are admitted or discharged from a Long Term Care facility, you will have access to early refills if necessary.
- Transition Across Plan Years
The list of covered formulary medications is subject to change from year to year. For this reason, we have a transition policy in place for current Elixir Insurance members who are taking a medication that will not be covered in the next plan year or medications that will have new step therapy, prior authorization, or quantity limit restrictions in the new plan year. In the first 90 days of the new plan year, Elixir Insurance will provide a temporary 30-day supply (unless you present a prescription written for less than 30 days in which case we will allow multiple fills to provide up to a total of 30 days of medication) of the requested non-formulary prescription drug (or drug that has new step therapy, prior authorization requirements, or quantity limit restrictions) when you have had a prescription for the same medication filled within the past 120 days of the date of the attempted fill.
- Emergency Transitions/Level of Care Changes
Members who are outside their transition period and experience a level of care change by moving from one treatment setting to another (e.g. long term care to hospital to long term care; hospitals to home; home to long term care; hospice to long term care; or hospice to home) will be able to receive a 30/31-day supply (30 days in the retail setting and 31 days in the long term care setting) for formulary medication upon admission or discharge from a treatment setting. Members will also be allowed an emergency 30/31-day supply (30 days in the retail setting and 31 days in the long term care setting) transition fill for non-formulary medications, including Part D covered drugs that are on the Elixir Insurance formulary but require prior authorization, step therapy, or quantity limit restrictions.
This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from long term care or hospital facilities.
Members who have passed the 90-day transition period may still be provided an emergency supply of non-formulary medications, if approved by us. If approved, members will receive up to a 30-day supply in the retail setting and up to a 31-day supply in the long term care setting. This will occur on a case-by-case basis, when it has been identified that an exception request or appeal has been filed but has not been completed by the end of the transition period. All transition fills for new members, either in the retail setting or in the long term care setting, will process automatically. If you require a transition fill outside of your first 90 days with Elixir Insurance, you or your pharmacist should contact Member Services at 1-866-250-2005, 7 days a week 24, hours a day (TTY: 711), so we can implement our transition policy for you.
In the event that you enroll in our plan while living at home, and then become a resident of a long term care facility, you need to contact Member Services at 1-866-250-2005, 7 days a week 24 hours a day (TTY: 711) to let Elixir Insurance know that you are now a resident of a LTC facility. This will allow us to implement the long term care transition policy for you.
We will send you written notice via U.S. first class mail within three business days of receiving your transition fill transaction from the pharmacy. This notice will contain an explanation of the temporary nature of that prescription fill; instructions on how to identify an appropriate therapeutic alternative that is on our formulary; an explanation of your right to request a formulary exception; and the procedure for requesting a formulary exception. Your prescriber will also receive a copy of this letter.
If you are a Low Income Subsidy member, you will never pay more for your transition fill than the appropriate copayment amount associated with your Low Income Subsidy Level. For members who do not have Low Income Subsidy status, you will pay the copay/coinsurance associated with our non-preferred drug tier for your transition fill.