Prescription Drug Transition Policy

Prescription Drug Transition Policy

Prescription drug transition policies allow your medications to adapt as you leave the hospital or a long-term care facility. CHRISTUS Health Plan will work with you to make sure you have the drugs you need regardless of where you receive care. This transition plan may include finding formulary alternatives or asking for an exception.

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 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply of medication. The prescription must be filled at a network pharmacy.
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 91 to 98-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 98-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.)

We will cover a 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.

For members whose transition window has expired and present a drug claim that is otherwise transition eligible, the claim will reject with appropriate reject codes returned to the pharmacy. There is additional messaging in these cases to inform the pharmacy to contact the help desk if a level of care change has occurred for the enrollee. Any time a pharmacy contacts the help desk as per the rejected claim messaging, a manual process is used to confirm whether or not a level of care change has occurred for the enrollee. When the process is invoked and a level of care change is confirmed, the help desk attendant provides a series of override codes to the calling pharmacy to allow a one-time transition supply to be dispensed and the associated notifications generated. This secondary reject messaging to the pharmacy and the associated manual process may also occur for a member still within their transition window who has already received a transition supply of the drug which satisfied the Plan’s transition obligation to the enrollee. In addition, the Plan is provided daily rejected claims data for oversight of these members experiencing a change in their care.

To ask for a temporary supply, call the Member Services number on your insurance card. 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. Learn how to request Part D coverage determinations and exceptions.


H1189_MM143 pending approval
Last Updated: 2/23/17