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Blue Cross Medicare Advantage (HMO)SM Blue Cross Medicare Advantage (HMO-POS)SM Blue Cross Medicare Advantage (PPO)SM Medicare Part D Transition Polic...
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Blue Cross Medicare Advantage (HMO)SM Blue Cross Medicare Advantage (HMO-POS)SM Blue Cross Medicare Advantage (PPO)SM Medicare Part D Transition Policy – CY 2017 HCSC Medicare Part D Medicare Part D Transition Policy This policy describes the transition requirements published by the Centers for Medicare and Medicaid Services (CMS) which state that all Part D sponsors must provide an appropriate transition benefit for members. This policy covers the following: • Eligible members • Applicable drugs • New prescriptions versus ongoing drug therapy • Transition time frames • Transition extensions • Transition across contract years for current members • Emergency supply for current members • Treatment of re-enrolled members • Level of care changes • Transition notices This policy describes how transition benefits apply when you are filling prescriptions in: • Long Term Care (LTC) settings • Retail pharmacies • Extended Supply Network (ESN) (90 days at retail setting) • Mail Order pharmacies Eligible members If you are currently taking drugs that are not included in your plan’s new formulary (drug list) from one year to the next, you may be eligible for a transition supply if you are: • New to the prescription drug plan at the start of 2017 • Newly eligible for Medicare Part D in 2017 • Switching from one Medicare Part D plan to another after January 1, 2017 • Affected by negative changes to the plan’s drug list from 2016 to 2017 • Living in an LTC setting _______________________________________________________________________________

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Medicare Part D Transition Policy – CY 2017 HCSC Medicare Part D

Applicable drugs The transition benefit allows members to receive a supply of eligible Part D drugs when the drugs are: • • •

Not on your plan's drug list Previously approved for coverage under an exception once the exception expires On your plan’s drug list but your ability to get the drug is limited o For example, under a Utilization Management (UM) program that require: • Prior Authorization (PA) • Step Therapy (ST) • Quantity Limits (QL)

You may be eligible for a transition supply of a drug in order to meet your immediate needs. This is meant to allow enough time for you to work with your doctor to find a similar drug on the plan’s drug list that will meet your medical needs or to complete a coverage determination to continue coverage of a drug you are currently taking based on medical necessity. An approved coverage determination request may allow continued coverage of a drug you are currently taking. Certain drugs may not be eligible for a transition supply at the pharmacy; these drugs first require a review to determine if they can be covered by your Part D plan. If you or your doctor want to request a coverage determination, the forms are available by mail, fax, email, and on our website; you can access the forms yourself or request a form be sent to you and/or your doctor. The plan reviews coverage determination requests and will notify you once a decision is made. If the plan does not approve the request, you will be provided with additional information regarding your options. You may qualify for refills of transition supplies that are dispensed for less than the written amount due to quantity limits, which may be used for safety purposes. New prescriptions versus ongoing drug therapy Transition benefits are applied at the pharmacy to new prescriptions when it is not clear if a prescription is for a drug you are taking for the first time or an ongoing prescription for a drug that is not on your plan's drug list. Transition time frames In outpatient settings (retail, ESN and mail order) If you are new or re-enrolled to the plan, you may be allowed a 30-day transition supply of eligible Part D drugs (unless the prescription is written for fewer days) any time during your first 90 days of coverage.

Medicare Part D Transition Policy – CY 2017 HCSC Medicare Part D In LTC settings You may be allowed a 31-day transition supply (unless the prescription is written for fewer days) of eligible Part D drugs during the following times: • Any time during the first 90 days of coverage in a plan you may get a 91-98 day transition supply, depending on how many days of medication are filled each time (31day supply per fill or greater if the package/drug cannot be reduced to a 31 day supply or less) • After the 90-day transition period has ended, if a coverage determination request is being processed you may be able get an emergency 31-day supply Transition extension The transition period may be extended on a case-by-case basis if the review of a coverage determination request or an appeal has not been processed by the end of your minimum transition period (first 90 days of coverage). The extension is then provided only until you have switched to a drug on the plan’s drug list or a decision on the coverage determination request or appeal is made. Transition across contract years for current members If you have not switched to a covered drug prior to the new calendar year, a transition supply may be provided if the following has occurred: • Your drugs are removed from the plan’s drug list from 2016 to 2017 • New UM requirements are added to your drugs from 2016 to 2017 If you are an existing member with recent history of using a drug which is not covered by your plan or you have limited ability to get the drug: •

In a retail setting you may get a 30-day transition supply (unless the prescription is written for fewer days) any time during the first 90 days of the calendar year



In a LTC setting you may get a 91-98 day transition supply (depending on how many days of medication are filled each time) any time during the first 90 days of the calendar year. There is a maximum of a 31-day supply per transition fill in LTC

This policy is in place even if you enroll with a start date of either November 1 or December 1 and need a transition supply. Emergency supply for current members If you are in a LTC setting, you may be allowed a 31-day emergency supply as part of the transition process, unless the prescription is written for fewer days, of a drug that is not on the drug list, or your ability to get the drug is limited. In the event that a coverage determination request is still being processed after the 90-day period, you may be able to get an emergency supply. Your LTC pharmacy can call to see if your fill qualifies as an emergency supply.

Medicare Part D Transition Policy – CY 2017 HCSC Medicare Part D Treatment of re-enrolled members You may leave one plan, enroll in another plan, and then re-enroll in the original plan. If this happens, you will be treated as a new member so you are eligible for transition benefits. The transition benefits begin when you re-enroll in your original plan. Level of care changes You may have changes that take you from one level of care setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s coverage determination request process. To prevent a gap in care when you are discharged, you may get a full outpatient supply that will allow therapy to continue once the limited discharge supply is gone. This outpatient supply is available before discharge from a Medicare Part A stay. When you are admitted to or discharged from an LTC setting, you may not have access to the drugs you were previously given. However, you may get a refill upon admission or discharge. Transition notices When you or your pharmacy submit a prescription drug claim for a transition supply, a letter is sent to you by first class U.S. mail within three business days of the date your drug claim is submitted. Efforts are made to notify doctors when a prescription they write for a member results in a transition supply. This letter is sent to explain the following information: •

That the transition supply is temporary and may not be refilled unless a coverage determination request is approved



That you should work with your doctor to find a new drug option that is on your plan’s drug list



That you can request a coverage determination and how to make the request, timeframes for processing requests, and the appeal rights if the coverage determination is not approved

Cost considerations You will be charged the cost share amount for a transition supply of drugs provided, as follows: • •

For low income subsidy (LIS) members, you will not be charged a higher cost sharing for transition supplies than the statutory maximum copayment amounts. For non-LIS enrollees, you will be charged: o The same cost share amount for Part D drugs that are not on the drug list that you would be charged for drugs approved through a formulary exception; or o The same cost share amount for drugs on the drug list with UM edits that would apply if the UM criteria are met.

Medicare Part D Transition Policy – CY 2017 HCSC Medicare Part D If you have any questions about our transition policy, need information about our most recent list of formulary drugs, or need help asking for a formulary or other utilization management exception, please call Customer Service at 1-877-774-8592. We are open 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays. TTY/TDD users should call 711. This information is available for free in other languages. Please call our Customer Service number at 1-877-774-8592 (TTY/TDD users should call 711). We are open between 8:00 a.m. and 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-877-774-8592 (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz). This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-ofnetwork services.

Blue Cross Medicare Advantage HMO plans in Montana, HMO and HMO-POS plans in Illinois and New Mexico, and PPO plans in Illinois, Montana, New Mexico, and Oklahoma are provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). Blue Cross Medicare Advantage PPO plans in Texas are provided by HCSC Insurance Services Company (HISC). Blue Cross Medicare Advantage HMO and HMO-POS plans in Texas are provided by GHS Insurance Company (GHS). Blue Cross Medicare Advantage HMO and HMO-POS plans in Oklahoma are provided by GHS Health Maintenance Organization, Inc. d/b/a BlueLincs HMO (BlueLincs) and by GHS Managed Health Care Plans, Inc. (GHS-MHC). HCSC, HISC, GHS, GHS-MHC, and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association. HCSC, HISC, GHS, GHS-MHC, and BlueLincs are Medicare Advantage organizations with a Medicare contract. Enrollment in Blue Cross Medicare Advantage plans depends on contract renewal.

Blue Cross and Blue Shield of Texas complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Texas does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Texas: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages If you need these services, contact Civil Rights Coordinator If you believe that Blue Cross and Blue Shield of Texas has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Y0096_MRK_TX_NDNOTICE17 Accepted 09042016

732356.0816

ATT NTION If you speak peak Engli h, language a i tance services, ervice , free of charge, are available avai able to you. you ATTENTION: English, assistance Call 1-877-774-8592 (TTY: 711). ATENCIÓN: español, tiene>)a su disposición servicios gratuitos de asistencia lingüística. Ca l ( Y ) ‫ تو آپ کو زبان کی مدد کی خدمات مفت میں دستياب ہیں‬،)‫ہيں‬ ‫اردومبولت‬ ‫اگر آ‬ TY ‫ (T < > kang gumamit ng mga serbisyo ng tulong sa TTY PAUNAWA: ng Tagalog, maaari wika nang बोलते हैं( TS तो आपक ललए मफ् ु त में भाषा सहायता सेवाएिं उपलब्ध हैं। Ap e eदें : e < -877 ) 1-877-774-8592 (TTY: 711) पर कॉल करें । ‫ با‬.‫باشد‬ ‫ملاشما افراهم‬ ‫رايگان برای‬ ‫اج می‬ ‫فارسی گفتگو‬ ‫اگر به زبان‬ ‫غ‬ ‫میف‬ ‫دخ ن‬ ‫صورت ةدعا‬ ‫زبانی ةبه وغل‬ ‫تسهيالت تت‬ ‫كل ر ا‬،‫ل کنيد‬ ‫ل تا‬ ‫ م‬:‫توجه‬ .‫ تماس بگيريد‬1-877-774-8592 (TTY: 711). ACHTUNG: stehen Ihnen ‫ تماس بگ‬Hilfsdienstleistungen ( zur ВНИ А И Wenn Е иSie в Deutsch говори еsprechen, а р сс ом е т kostenlos а ст sprachliche п ы‫ري‬беспл ны луги пе ево аY Verfügung. Зв ните < Rufnummer: 877-774-85 1-877-774-8592 (TTY: 711). સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો (TTY: 711).

1-877-774-8592

‫رادربخ‬ ‫ پآ رگا‬Если ‫لوب ودر‬ ‫ںیہ ے‬، ‫و‬на ‫پآ‬русском ‫ن بز وک‬языке, ‫ م یک‬то ‫یک د‬ ‫ خ‬доступны ‫ںیم تفم ام‬ ‫ب یتسد‬ ‫ ںیہ‬перевода. ‫یرک لاک‬ ВНИМАНИЕ: вы говорите вам бесплатные услуги ) Звоните 1-877-774-8592 (телетайп: 711). HÚ Ý u ạn nó T ếng V ệt, c ác d ch vụ hỗ trợ n ôn ng miễn phí d 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。 1-877-774-8592 (TTY: 711) Gọi s TTY < まで、お電話にてご連絡ください。

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