Drug Transition Policy
Under certain circumstances, CareSource can offer a temporary supply of a drug to you when your drug is not on the drug list or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
During the first 90 days of enrollment, CareSource covers a one-time, temporary supply of a non-formulary drug. CareSource extends up to a one-month transition supply of medication (unless the prescription is written for fewer days) to members for drugs that are not on our formulary as well as drugs with restrictions or limits.
Call Member Services at 1-844-607-2827 (TTY: 1- 800-750-0750 or 711) to find out more. We are open 8 a.m. to 8 p.m. EST, seven days a week from October 1 to February 14, and Monday through Friday the rest of the year.
To be eligible for a temporary supply, you must meet the two requirements below:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan’s drug list.
- The drug you have been taking is now restricted in some way.
- You must be in one of the situations described below:
- For those members who are new or who were in the plan last year and aren’t in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
- For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
Long-term Care Facility Members
Long-term care facility members receive up to a 31-day supply, unless the enrollee presents a prescription written for less than 31 days, and they are entitled to refills (up to a 31-day supply), as necessary, during the transition period (first 90 days on the plan, beginning on the enrollee’s effective date of coverage or when admitted into a qualified long-term care facility).
Additionally, institutionalized members are allowed a 31-day supply, when a qualifying level of care change has occurred, which affects the enrollee’s ability to obtain a Part D non-formulary drug, for example, when an enrollee’s Part A coverage expires. The CareSource Medicare Advantage pharmacy benefit manager will verify the “level of care” change by confirming admission date of the member and the type of facility in which the member will reside.
Assisted living facilities, retirement homes or other non-skilled group homes are not deemed by CMS to be an approved institutional setting and thereby do not qualify for the long-term care transition protocols.
Request a Temporary Supply
To ask for a temporary supply, call Member Services at 1-844-607-2827 (TTY: 1-800-750-0750 or 711) to find out more. We are open 8 a.m. to 8 p.m. EST, seven days a week from October 1 to February 14, and Monday through Friday the rest of the year.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
CareSource is an HMO with a Medicare contract. Enrollment in CareSource Advantage® Zero Premium (HMO), CareSource Advantage® (HMO) and CareSource Advantage Plus® (HMO) depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
CMS Accepted 9/25/2018