Advantage D-SNP Medicare Part D Drug Transition Process

At Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP (HMO), we understand that navigating drug coverage can be complex—especially when you’re new to the plan or changes to our List of Covered Drugs (Formulary) impact the drugs that you use. That’s why we offer a Medicare Part D Transition Process to ensure you don’t experience a gap in treatment.

Some members new to Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP may already have used certain drugs prior to enrolling into our plan.  Those drugs may have certain rules, such as prior authorization or step therapy that impacts their ability to easily continue the use of those drugs.  Current members can also be affected by changes to our Drug List from one plan year to the next.

For drugs that are not on our Drug List or have some type of rule that limits access to a drug that you have been taking prior to joining our plan or when the plan year changes, we can give you a temporary supply of the drug.  This will allow you time to talk to your provider about getting a different drug or to ask us to cover the drug.

The List of Covered Drugs (Formulary) is a list of some drugs or items covered under Medicare Part D.  For drugs or items that are not listed on the List of Covered Drugs (Formulary), Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP may cover them.

You may qualify for a transition supply if:

• You are new to Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP and are currently taking medications that are:
  • Not on our Part D formulary, or
  • Covered but with restrictions (such as prior authorization, step therapy, or quantity limits), and
• You are within your first 90 days of enrollment in Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP.

You may also qualify if you are:

• An existing member who is affected by formulary changes from one plan year to the next, or

Experiencing a change in level of care—for example, being discharged from a hospital or long-term care facility.

Our transition process applies to Part D drugs that are:

• Not on our current formulary (non-formulary drugs),
• On our formulary but require prior authorization, step therapy, or have quantity limits, and you have not yet received approval, or
• Affected by changes in your level of care setting.

Please note: Over-the-counter (OTC) products and drugs not covered under Medicare Part D by law are not eligible for a transition supply.  However, please refer to our supplemental benefits regarding OTC coverage.

If you qualify, Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP will provide a temporary supply of your drug:

• Retail and Mail-Order Pharmacies: Up to a 30-day supply (or less if the prescription is written for fewer days).
• Long-Term Care (LTC) Pharmacies: Up to a 31-day supply, with refills allowed during the 90-day transition period, if needed.

This temporary fill allows you time to talk with your provider about:

• Switching to a similar drug on our formulary, or
• Requesting a formulary exception if your medication is medically necessary.

After You Receive a Transition Fill

We’ll send you a written notice explaining:

• Why your medication was covered temporarily,
• What steps you can take to continue your therapy,
• How to switch to a covered drug or request a coverage exception,
• Your appeal rights and how to request a coverage determination.

You, your doctor, or an authorized representative (Appointment of Representative Form) can request a coverage determination (including formulary exceptions) by:

• Phone: 1-833-546-0796 | TTY: 711
• Fax: 1-858-790-7100
• Mail:
  
  HEALTH PLAN OF SAN JOAQUIN
  10181 SCRIPPS GATEWAY CT.
  Ste. 200
  SAN DIEGO, CA 92131

• Online

We will process your request promptly and inform you of our decision within the required timeframes.