Transition Policy
Transition Policy Statement
As a new or continuing member to our plan, you may be taking medications that are not on our
formulary (the list of drugs covered by TexanPlus® HMO). Or, you may be taking medications that are included on the formulary, but have a coverage restriction. 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 that you take. While you talk to your doctor about the right course of action, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your medications that is not on our formulary or has a coverage restriction, we will cover a temporary 30-day transition supply (or less if your prescription is written for fewer days) when you go to a network pharmacy. After your first 30-day supply (or less if your prescription is written for fewer days), we will not continue to pay for these medications under the transition policy, even if you have been a member for less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day and may be up to 98-day transition supply, consistent with the dispensing increment (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 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
If you are already a TexanPlus member, we will also cover a temporary transition supply if you have a change in your medications because of a level-of-care change. This may include unplanned changes in treatment settings, such as being discharged from an acute care (hospital) setting or being admitted to, or discharged from, a long-term care facility. For each medication that is not in our formulary or has a coverage restriction, we will cover up to a temporary 30-day supply (or up to a 34-day supply if you are a resident of a long term care facility) when you go to a network pharmacy.
If you receive a transition supply, you will also receive a letter notifying you that you have received a temporary supply of your medication.
View a copy of the Medicare Part D Transition Letter:
If you are already a TexanPlus member, you will receive your Annual Notice of Change (ANOC) by September 30, 2011. You may notice that a medication you currently take is either not on the upcoming plan year's formulary, or now has a coverage restriction. You may also have a current formulary exception that will end before the new plan year. In either of these scenarios, you should talk to your doctor about formulary alternatives. If your doctor believes that your medical condition cannot be treated by the alternative medications on our formulary, you or your doctor can request a formulary exception.
Print Exception and Prior Authorization forms, or use our easy Drug Search tool to find the forms you need.
If you have any questions about our transition policy or need help asking for a formulary exception, contact a Member Advocate at 1-866-230-2513, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week.