Prescription Drug Transition Policy

Prescription Drug Transition Policy for:

West Virginia Senior Advantage (HMO 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)

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. West Virginia Senior 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. West Virginia Senior Advantage will honor multiple fills of non-formulary Part D medications, including Part D medications that are on West Virginia Senior Advantage’s formulary but require prior authorization or step therapy under West Virginia Senior 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 West Virginia Senior Advantage will provide an emergency supply of non-formulary medication, including Part D medications that are on West Virginia Senior Advantage’s formulary but require prior authorization or step therapy under West Virginia Senior 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 West Virginia Senior 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, West Virginia Senior Advantage will provide an emergency supply of non-formulary medication, including Part D medications that are on West Virginia Senior Advantage’s formulary but require prior authorization or step therapy under West Virginia Senior 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 West Virginia Senior Advantage. West Virginia Senior 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. West Virginia Senior 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.

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 West Virginia Senior Advantage Member Services Department at our toll-free number: 1-844-854-6888 (TTY: 711), between 8:00 a.m. – 8:00 p.m., 7 days a week from October 1 to March 31; and 8:00 a.m. –8:00 p.m., Monday to Friday from April 1 to September 30.

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 West Virginia Senior Advantage Member Services Department at our toll-free number: 1-844-854-6888 (TTY: 711), between 8:00 a.m. – 8:00 p.m., 7 days a week from October 1 to March 31; and 8:00 a.m. –8:00 p.m., Monday to Friday from April 1 to September 30.