Employees Retirement System of Texas
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Prescription Drug Transition Process


HealthSelectSM Medicare Rx (PDP) Plan

What to do if your current prescription drugs are not on the formulary or are limited on the formulary.

New members

As a new plan member, you may currently be taking drugs that are not on the plan’s formulary (drug list), or they are on the formulary but your ability to get them is limited.

In instances like these, start by talking with your doctor about appropriate alternative medications available on the formulary. If no appropriate alternatives can be found, you or your doctor can request a formulary exception. If the exception is approved, you may be able to obtain the drug for a specified period of time. While you and your doctor are determining your course of action, you may be eligible to receive a transition supply of at least a 1-month supply as described in your plan’s Evidence of Coverage of most drugs anytime during the first 90 days you are a plan member.  If the prescription is written for fewer days, multiple fills are allowed until you’ve received at least a 1-month supply of your drug as described in your plan’s Evidence of Coverage.  After your transition supply, these drugs may not continue to be covered.

If you live in a long-term care facility but you are past the first 90 days of plan membership, the transition program may cover at least a 31-day emergency supply of most drugs while you pursue a formulary exception.

You may face unplanned transitions after the first 90 days of plan enrollment, such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care). For many drugs that are not on the formulary or your ability to get your drug is limited, you are required to use the plan’s exception process. You can request a one-time temporary supply of at least a 1-month supply as described in your plan’s Evidence of Coverage to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception. 


Continuing members

As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). You may notice that a formulary drug you are currently taking is either not on the upcoming year’s formulary or its cost sharing or coverage is limited in the upcoming year.

Starting October 15, 2018, you may request a 2019 coverage review. If your request is  approved, the plan will cover the drug as of January 1, 2019.

If your drug is subject to new formulary restrictions and you have not discussed switching to an alternative formulary medication or pursued a formulary exception with your doctor, you may receive a temporary supply when you go to a network pharmacy. This would be at least a 1-month supply as described in your plan’s Evidence of Coverage to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you live in a long-term care facility, you can obtain multiple refills until you’ve reached at least a 31-day  supply, including when prescriptions are dispensed for less than the written amount due to drug utilization edits that are based on approved product labeling.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Part D coverage or when taken off of hospice care) that can occur anytime. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is limited, you are required to use the plan's exception process. For most drugs, you may request a one-time temporary supply of at least one month as described in your plan’s Evidence of Coverage to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility and need an emergency supply, you may receive up to at least a 31-day temporary supply.

If you have any questions about this transition policy or need help asking for a formulary exception, please contact UnitedHealthcare Customer Service.

 

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IMPORTANT DATES

2019 Open Enrollment Period

Began: 10/29/2018
Ended: 11/16/2018


IMPORTANT INFORMATION

Information on your new Medicare card  

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Last updated: 09.26.2018 at 12:01 AM  S5820_180905_012808_M