Transition Process

Question: What if my current prescription drugs are not on the formulary or are limited on the formulary?

Answer: We have defined a transition process for ensuring access to prescription drugs for existing members who are affected by a formulary change or for new members enrolled in a plan whose formulary does not cover their prescribed drug.

New Members

As a new member in our plan, you might currently be taking drugs that are not on our formulary, or they are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period. While you are talking with your doctor to determine your course of action, you might be eligible to receive an initial 34-day transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 34-day transition supply, we may not continue to pay for these drugs under the transition policy.

If you are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Continuing Members

As a continuing member in the plan, you will receive your Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) by October 1. You may notice that a formulary medication that you are currently taking either is not on the upcoming year’s formulary or its cost-sharing or coverage is limited in the upcoming year. In this case, we will provide a transition period consistent with the above transition process for new enrollees.

Change in level of care:

Members who have a change in their level of care will be allowed a one-time, 34-day transition supply per drug.
If patients have more than one change in their level of care in a month, the pharmacy will have to call the plan for an extension.

If you have any questions about our transition policy or need help asking for a formulary exception, please contact us.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions.

Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 NJ HMO will be responsible for the costs.

Please contact AmeriHealth 65 HMO for more information.

In lots of cases, your prescriptions are covered under AmeriHealth 65 NJ HMO, AmeriHealth Rx PDP if they are filled at a network pharmacy or through our mail-order pharmacy service. There are thousands of network pharmacies, including:

national chain and independent retail pharmacies
long-term care and home-infusion pharmacies
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies

Website last updated: 12/30/11
Y0041_HNS_12_301a Pending CMS Approval