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 medications that are included on the formulary, but coverage and/or cost-sharing may be limited.

In either of these scenarios, you must talk to your doctor about available formulary alternatives. If your doctor determines that there are no alternative medications on our formulary, you or your doctor can request a formulary exception. The formulary exception process enables you or your doctor to submit pertinent clinical information to support why you require a non-formulary medication, or a medication that has limited coverage and/or cost-sharing. If your formulary exception request is approved, you will be able to receive the medication for the period of time specified in the approval letter.

For more information on how to request a formulary exception, visit the Exceptions and Prior Authorization page.

While you and your doctor are determining the best course of action, you may be eligible to receive a temporary 30-day transition supply (or less if your prescription is written for less than a 30-day supply) of the medication anytime during your first 90 days as a member of our plan.

For each of your medications that is not on our formulary, or has limited coverage and/or cost-sharing, we will cover a temporary 30-day transition supply (or less if your prescription is written for less than a 30-day supply) when you go to a network pharmacy. After your first 30-day supply (or less if your prescription is written for less than a 30-day supply), we will not continue to supply these medications under the transition policy.

If you are a resident of a long-term care (LTC) facility, we will cover a temporary 34-day transition supply (or less if your prescription is written for less than a 34-day supply). We will cover multiple refills of these medications, up to a total of a 93-day supply, within the first 90 days you are a member of our plan. If you need a medication that is not on our formulary, or has limited coverage and/or cost-sharing, and you are beyond the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that medicine while you pursue a formulary exception.

If you are already a TexanPlus member, we will cover a temporary transition supply of medication if you have a change in your medications due to a level-of-care change. A level-of-care change 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 drug that is not in our formulary, or if it has limited coverage and/or cost-sharing, we will cover a temporary 30-day supply (or less if your prescription is written for less than a 30-day supply), or a 34-day supply (or less if your prescription is written for less than a 34-day supply) if you are a resident of a long term care facility.

If you are already a TexanPlus member, you will receive your Annual Notice of Change (ANOC) by October 31. You may notice that a medication you currently take is either not on the upcoming plan year's formulary, or now has limited coverage and/or cost-sharing. You may also have a current year formulary exception that will no longer be honored in the upcoming plan year. In either of these scenarios, you must talk to your doctor about available formulary alternatives. If your doctor determines that there are no alternative medications on our formulary, you or your doctor can request a formulary exception prior to January 1st of the upcoming plan year. If your formulary exception request is approved, payment will be authorized prior to January 1st and coverage will begin on January 1st. You will be able to receive the medication for the period of time specified in the approval letter.

For more information on how to request a formulary exception, visit the Exceptions and Prior Authorization page.

If you have any questions about our transition policy or need help asking for a formulary exception, contact a Customer Service Representative at 1-866-230-2513 from 8 a.m. to 8 p.m., everyday. TTY users should call 1-800-958-2692.