Bright HealthCare Medicare Advantage prescription medication transition policy.
For Medicare Advantage members,who may be affected by formulary changes,or members who are new to Bright HealthCare, we want to make sure your transition is as seamless as possible. That’s why we have policies in place for any prescription medications you are taking.
Bright HealthCare’s goal is to make changes that occur each new benefit year as seamless as possible. Our transition policy meets the immediate needs of our members and allows you time to work with your provider to switch to another medication that is on the covered drug list (formulary) to treat your condition or ask for an exception.
Who is eligible for a temporary transition supply?
During the first 90 days of membership, we offer a temporary supply of medication to:
- New members into prescription drug plans following the Annual Election Period
- Newly eligible Medicare members from other coverage
- Members who switch from one plan to another after the start of a contract year
- Current members affected by negative formulary changes across contract years
- Members residing in long-term care (LTC) facilities, including members admitted to, or discharged from, an LTC facility
Bright HealthCare will ensure system capabilities are in place to allow a temporary supply of Part D medications that are not on our formulary and Part D medications that are on our formulary, but may require:
Prior authorization (PA)- These medications need to be approved in advance before we cover them.
Step Therapy (ST)- These medications require your provider to first try certain medications to treat a medical condition before we will cover another medication.
Quantity limits (QL)- These medications have limits for a certain amount over a certain time. If your provider thinks you need to receive more, you or your provider may ask for an exception.
Transition in a Non-LTC Setting
In a non-LTC setting, members are allowed a one-time, temporary fill of at least a 30-day supply of medication anytime during the first 90 days of enrollment in a plan, beginning on the member’s effective date of coverage.
Transition in an LTC Setting
If a member is in an LTC setting, the transition process will include the following:
One-time, temporary fill of at least a 31-day supply, anytime during the first 90 days of a member’s enrollment in a plan, beginning on the effective date of coverage.
A 31-day, emergency supply of non-formulary Part D medications while an exception or prior authorization determination is pending for members being admitted to, or discharged from, an LTC facility, early refill edits will not be used to limit appropriate and necessary access to their Part D benefit.
Extended Transition Period
Bright HealthCare will provide a process for members to receive necessary Part D medications via an extension of the transition period, on a case-by-case basis, to the extent that their exception requests or appeals have not been processed by the end of the minimum transaction period and until such time as a transition has been made (either through a switch to an appropriate formulary medication or a decision on an exception request).
The cost share for the medication received through transition will be based one of Bright HealthCare’s approved formulary tiers.
Non-formulary Part D medications will receive the same cost sharing that would apply for a nonformulary medication approved through a formulary exception.
Formulary medications that require prior authorization, step therapy, or have a quantity limit will receive the same cost share that would apply if granted approval upon clinical review.
For Low-Income Subsidy (LIS) Eligible Members
The cost-share tier, for a temporary supply of medication, provided through the transition process will not exceed the statutory maximum co-payment amounts for low-income subsidy (LIS) eligible members.
Member and Prescriber Notification
Bright HealthCare will send written notification, within three business days of adjudication of a temporary transition fill. The notice will include:
An explanation of the temporary nature of the transition supply a member has received.
Instructions for working with Bright HealthCare and the member’s provider to satisfy utilization management requirements or to identify appropriate therapeutic alternatives that are on Bright HealthCare’s formulary.
An explanation of the member’s right to request a formulary exception.
The procedures for requesting a formulary exception.
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Website Last Updated: Nov 21 2021