Prescription Drug Transition Policy
What can you do if a drug you are taking is not on the List of Drugs? What if the drug is restricted in some way? If your drug is not on the List of Drugs or is restricted, here are things you can do:
- You can change to another drug.
- You can ask for an exception and ask Michigan Complete Health (MMP) to cover the drug.
- You may be able to get a temporary supply.
A temporary supply is a short supply of drugs that gives you time to talk with your doctor about getting a different drug or to ask the plan to cover the drug. You may be able to get a temporary supply for a drug that is not on the formulary or is limited in some way. To be eligible for a temporary supply, you must meet BOTH of the two rules below:
1. The drug you have been taking:
- Is no longer on Michigan Complete Health (MMP)'s Drug List OR
- Was never on Michigan Complete Health (MMP)'s Drug List OR
- Is now limited in some way
2. AND You must be in one of the situations listed below:
For Medicare Part D Drugs:
- You were in the plan last year and do not live in a long-term care facility. We will cover a short supply of your drug for the first 90 days of the year. This short supply will be for up to a 30 day supply. Your doctor may not let you have the whole 30 day supply at one time. We will allow multiple fills of the drug up to a maximum of a 30 day supply. You must fill the drug at a network pharmacy.
- You are new to the plan and do not live in a long-term care facility. We will cover a short supply of your drug for the first 90 days on the plan. This short supply will be for up to a 30 day supply.
- You are new to the plan and live in a long-term care facility. We will cover a short supply of your drug for the first 90 days on the plan. The total supply will be for up to a 93-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 93-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.)
- You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away. We will cover one 31-day supply. We will cover less than a 31-day supply if written for fewer days. This is in addition to the above long-term care transition supply.
Throughout the plan year you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you need. These transitions may include, but are not limited to:
- Members who are discharged from a hospital or skilled-nursing facility to a home setting
- Members who are admitted to a hospital or skilled-nursing facility from a home setting
- Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy
- Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit
- Members who give up Hospice Status and go back to standard Medicare Part A and B coverage
- Members discharged from psychiatric hospitals with highly individualized drug regimens
For these changes in treatment settings, Michigan Complete Health (MMP) will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your drug at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks.
For Michigan Medicaid drugs:
- You are new to the plan.
We will cover a supply of your Michigan Medicaid drug for up to 90 days after enrollment and will not terminate it at the end of the 90 days without advance notice to you and a transition to another drug, if needed.
To ask for a temporary supply of a drug, call Member Services.
When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:
- You can change to another drug:
There may be a different drug covered by Michigan Complete Health (MMP) that will work for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.
- You can ask for an exception:
You or your provider can ask Michigan Complete Health (MMP) to make an exception. For example, you can ask Michigan Complete Health (MMP) to cover a drug even though it is not on the Drug List, or you can ask Michigan Complete Health (MMP) to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.
If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception before next year. We will tell you about any change in the coverage for your drug for next year. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. We will answer your request for an exception within 72 hours after we get your request (or your prescriber’s supporting statement).
Last Updated: 09/30/16