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Prescription Drug Transition Policy for:

Simpra Advantage (PPO I-SNP) and 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)

New Member (first 90 days of membership)

As a new member, you may be taking drugs that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Simpra Advantage will cover a temporary 30-day (retail) or 90-day (long-term care) supply of a drug during the first 90 days of your enrollment.

This will give you time to talk to your doctor. Your doctor can help you decide if there is an alternative drug on the Covered Drug List that you can use instead, or whether you should request an exception.

In outpatient settings (retail and mail order)

If you are new or re-enrolled to the plan, you may be allowed a 30-day transition 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 the member’s first 90 days of enrollment the member can obtain up to a 90-day transition supply. Simpra Advantage will honor multiple fills of non-formulary Part D medications, including Part D medications that are on Simpra Advantage’s formulary but require prior authorization or step therapy under Simpra Advantage’s utilization management rules, as appropriate during the entire length of the 98-day transition period.

If the member is outside of his or her 98-day transition period Simpra Advantage will provide an emergency supply of non-formulary medication, including Part D medications that are on Simpra Advantage’s formulary but require prior authorization or step therapy under Simpra Advantage’s utilization management rules. This emergency supply will be for at least 31 days of medication, unless the prescription is written for less than 31 days. The emergency supply is to ensure that members receive their medications while an exception has been requested through Simpra Advantage.

There are times when a member may experience an unplanned level of care change. For example, being admitted to a hospital or nursing facility skill level changes, etc. In these instances, Simpra Advantage will provide an emergency supply of non-formulary medication, including Part D medications that are on Simpra Advantage’s formulary but require prior authorization or step therapy under Simpra Advantage’s utilization management rules. This emergency supply will be for at least 31 days of medication, unless the prescription is written for less than 31 days. The emergency supply is to ensure that members receive their medications while an exception has been requested through Simpra Advantage. Simpra Advantage will cover up to a temporary 31-day transition supply, unless your prescription is for less than 31 days or the drug is limited to a smaller dispensing amount. Simpra Advantage will cover more than one refill of these drugs for the first 90 days for members, and up to a 98-day supply. If you need a drug that is not on the formulary or your ability to get your drugs is limited, but you are past the first 90 days of plan membership, the transition program will cover a 31-day emergency supply of that drug, unless your prescription is for less than 31 days, 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 the member has 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 a utilization management (UM) criteria, or making more restrictive. (Prior Authorization, Step Therapy, Quantity Limits)

In outpatient settings (retail and mail order)

If you are new or re-enrolled to the plan, you may be allowed a 30-day transition 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 Members

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 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). If you need a medication that is not on our formulary or if your ability to get your medications is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that medication, unless you have a prescription for fewer days, while you pursue 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. In some cases, we will contact you if you are taking a drug that is not on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of the drugs are an option for your treatment.

If you have any questions about our transition policy, call the Simpra Advantage Member Services Department at our toll-free number: 1-844-637-4770 (TTY 711) 

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