Prescription Drug Transition Policy
Prescription Drug Transition Policy for:
- Simpra Advantage (PPO I-SNP)
- Simpra Advantage Premier (PPO I-SNP)
- Simpra Advantage (PPO D-SNP)
What should you do if your current prescription drugs are not on the drug list (formulary) or are limited on the drug list (formulary)?
Our Prescription Drug Transition Policy
New Member (First 90 days of membership)
As a new member in our plan, you may be taking drugs that are not on our formulary or that are subject to utilization management restrictions, such as prior authorization or step therapy. You should talk to your doctor to decide if you can switch to an alternative drug on the Covered Drug List or whether you should request an exception. To give you time to speak to your doctor about the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
In outpatient settings (retail and mail order)
If you are new or re-enrolled to the plan, you may be allowed a 30-day temporary supply of eligible Part D drugs (unless the prescription is written for fewer days) any time during your first 90 days of coverage.
Long-Term Care (LTC) Members
During your first 90 days of enrollment, if you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 31-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). Simpra Advantage will honor multiple fills of non-formulary Part D medications and drugs with utilization management requirements (Prior Authorization, Step Therapy, and Quantity Limits), as appropriate during the entire length of the 90-day transition period.
If you need a drug that is not on our formulary and you are past the first 90 days of membership in our plan, we will cover up to a 31-day emergency supply of that drug while you pursue a formulary exception.
Continuing Members (After 90 days of membership)
As a continuing member, you receive an Annual Notice of Change (ANOC). You may notice that a formulary medication which you are currently taking is either not on the upcoming year’s formulary or its cost sharing or coverage is limited in the upcoming year. Existing members will receive the allotted transition supply for only those drugs that have been identified as a negative change from the previous year’s formulary and for which you had a history of in the last 180 days. CMS considers a negative formulary change to include the following: removal of a drug from a formulary, adding utilization management criteria, or making more restrictive (Prior Authorization, Step Therapy, Quantity Limits).
Simpra Advantage will send written notices via U.S. first class mail to you and fax your prescriber within three business days of the start of a temporary fill. The letter will contain:
- an explanation of the temporary nature of the transition fill supply received
- instructions for working with Simpra Advantage and your prescriber to satisfy prior authorization requirements or non-formulary exception requirements
- an explanation of your right to request a formulary exception
- a description of the procedure for requesting a formulary exception
Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are purchased at a network pharmacy. The transition policy cannot be used to purchase a non-Part D drug or drug out-of-network.
If you have any questions about our transition policy, please call the Simpra Advantage Services Department at our toll-free number: 1-844-637-4770 (TTY 1-833-312-0044).