2023 Transition of Care

Background
The Centers for Medicare and Medicaid Services (CMS) require Part D Plan Sponsors, like Harvard Pilgrim Health Care, to have a transition of care drug coverage process. Members taking Part D drugs that are either not on our formulary (list of covered drugs) or have restrictions can get a temporary supply of their drug in certain circumstances. This gives members the opportunity to avoid disruption in their treatment while they work with their provider to switch to a drug on our formulary, or request we cover their drug.

How it works
Both new and continuing members are eligible for a temporary supply, or “transition fill” of Part D drugs in certain circumstances. The information below details when and how transition fills are provided.

What drugs?
Part D drugs that are not on our formulary, or are on our formulary but have quantity limits, require prior authorization, or are subject to step therapy requirements will be eligible for transition fills. Quantity limits that are in place for safety reasons are not overridden for transition of care. Similarly, prior authorization may still be required for drugs that have the potential to be used for non-Part D covered conditions.

Member status

• New Members are eligible for transition fills during their first 108 days of joining our plan
• Continuing Members are eligible for transition fills during the first 108 days of the 2023 plan year if they are filling a drug that they were using in the previous plan year (2022) that has undergone a negative change (e.g. the drug was removed from the formulary effective 1/1/2022 or now requires prior authorization)

Quantity of the transition fill

• We will provide a up to a 30-day supply, and if your prescription is written for fewer days, we will allow multiple fills until you have received a 30-day supply

What pharmacies?
Transition fills must be obtained at a pharmacy in our network. To see if your pharmacy is in our network, use our pharmacy locator.

After you receive a transition fill
We will send you a letter after you fill a prescription that is a transition fill. The letter will tell you why you received a temporary supply and what limits or restrictions apply to your drug. It will also tell you how to switch to a drug on our formulary or how to request we cover your drug.

For detailed information about this process, view our Transition of Care Policy.

Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Stride℠ (HMO) depends on contract renewal.

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