As a new member to Leon Medical Centers Health Plans, you may currently be taking Part-D approved medications that are on our formulary but may require prior authorization, step therapy trial or other Medicare approved utilization management rules. In cases like this you will need to speak with your physician about appropriate alternative therapies that may be available. If there are no appropriate alternatives available you or your doctor can request a formulary exception. If the formulary exception is approved you will be able to obtain the medication for a specified period of time.
If you are identified as a transition member you will be eligible to receive a transition fill and will be sent a letter with instructions on how to proceed with the Exception Process. The following scenarios may apply to the Transition Process:
• The transition of new enrollees into prescription drug plans following the annual coordinated election period;
• The transition of newly eligible Medicare beneficiaries from other coverage;
• The transition of individuals who switch from one plan to another after the start of the contract year;
• Members who change in level of care (ex. Home to Long Term Care, Home to Hospital, or Long Term to Home).
• Enrollees residing in LTC facilities; and,
• In some cases, current enrollees affected by formulary changes from one contract year to the next.
If you have not had an opportunity to speak with your physician and you are within the first 90 days of membership in our plan (known as the Transition Period) you may be eligible to receive an initial 30-day supply of the medication (unless you have a prescription written for fewer days) when you visit a network pharmacy. After your first 30-day transition supply we may not pay for the medication again, even if your are still within the transition period. You are encouraged to speak with your physician as soon as possible to discuss alternative therapies that may be available. If there are none then you or your physician can request a formulary exception.
If you are residing in a long-term care facility, we will cover a 31-day transition supply (unless you have a prescription written for fewer days). You are encouraged to speak with your physician as soon as possible to discuss alternative therapies that may be available. If there are no alternatives then you or your physician can request a formulary exception. We will cover more than one refill of medication, should you require it, during your transition period while you pursue a formulary exception.
FOR MORE INFORMATION:
For more detailed information about your Leon Medical Centers Health Plans prescription drug coverage, please review your 2016 Evidence of Coverage. If you have questions about Leon Medical Centers Health Plans, please call Member Service at (305) 559.5366 or Toll Free 1(866).393.5366, 7 days a week, from 8:00 am to 8:00 pm, Eastern Standard Time. TTY users should call 711. Or visit www.lmchealthplans.com
If you have general questions about Medicare prescription drug coverage, please call Medicare a 1(800) MEDICARE 1(800)633-4227 24 hours a day/7 days a week. TTY/TDD users should call 1(877)486-2048. Or, visit www.medicare.gov.