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Granite Alliance Formulary Transition Policy

Granite Alliance understands that prior to joining our plan you may have been taking a medication that is considered non-formulary or has certain requirements that must be met for the drug to be covered by our plan. We have a formulary transition process in place, in compliance with CMS rules and guidance, that allows you to receive a temporary one-month supply of this medication during the first 90 days of membership in our plan. This temporary supply allows you to time to work with your doctor to either transition to a new drug or request a formulary exception to continue taking your current drug.   

A transition supply is available to you if your current drug therapy is not covered by the plan, or your drug is on the formulary but subject to prior authorization (PA), step therapy (ST), or quantity limit (QL) restrictions based on our utilization management program.  A transition supply will not be covered for drugs that are excluded from Medicare Part D, drugs that may be covered under Medicare Part A, B or D where the dose exceeds safety limits, or drugs that require determination of medically accepted indication for Medicare Part D coverage.   

If you are granted a transition supply, you will receive a letter from us informing you that you have received a temporary supply of your prescription drug. This letter also includes a detailed explanation of the transition benefit, instructions on how to work with your doctor to decide whether you should switch to a different medication, how to request a formulary exception and what your rights are regarding exceptions. To learn more about our formulary transition policy, go to Chapter 3 of your Evidence of Coverage.

Who is eligible for a transition supply?

Eligible members may include:

  • New plan members enrolled during the annual coordinated election period
  • Newly eligible Medicare beneficiaries enrolled into the plan
  • Enrollees with an effective enrollment date of either November 1 or December 1 (provided a 90-day transition period extending across the following contract year) 
  • Current plan members affected by negative formulary changes across contract years
  • Current plan members residing in long-term care (LTC) facilities
  • Discharged from a hospital or psychiatric hospital
  • Ending stay at a Skilled Nursing Facility
  • Revert from Hospice to standard Part A or Part B

For those members who are new to our plan, we will cover a temporary supply of your drug during the first 90 days of your membership and will provide at least a 30-day supply. For members who were in the plan last year, we will cover a temporary supply of your drug if there was a negative formulary change from the previous year. Negative formulary changes can include:

  • Removal of a drug from your formulary
  • Increasing the cost-sharing status of a drug (moving it to a higher tier level)
  • Adding, or making the drug more restrictive (such as adding PA, QL, or ST requirements)
  • Imposing other restrictions on a drug that require CMS approval
  • If a previously approved exception expires

You must have received a prescription for the medication within the last 180 days for us to cover the temporary supply. In the cases above, if your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. The transition prescription must be filled at a network pharmacy.

Transition Fill in a Retail Setting

At any time within your first 90 days of coverage, Granite Alliance provides a temporary fill of at least a month’s supply (30 days) of your current medication at a retail setting.  For prescriptions written for a supply less than a month’s supply (30 days), the written amount will be prescribed.

Transition Fill in a Long Term Care (LTC) Setting

If you live in an LTC  facility and were taking a non-formulary or restricted medication prior to enrolling in the Granite Alliance plan, you are eligible for a transition fill of at least a month’s supply (31 days) during your first 90 days in the plan.  

As an LTC resident you are also entitled to a 31-day emergency supply of non-formulary medication for Part D medication while a request for an exception or prior authorization is being requested and reviewed. If the prescription was written or filled for less than a 31-day supply, multiple fills are allowed until the member receives an accumulated 31-day supply. Emergency supplies may occur at any time while in an LTC and are not subject to the transition benefit period.

If your drug isn’t covered by Granite Alliance

It can be frustrating and stressful to learn that a medication you take isn’t covered. No two Medicare prescription drug plan formularies are exactly alike, and because of that your current medication(s) may not be covered under our formulary. We hope you will consider taking certain steps to get your medication needs met as a Granite Alliance member.

Discussing your situation with your doctor will help you determine the right course of action for your medical condition. Your doctor may suggest an appropriate alternative drug that is covered by our formulary, or you may be able to get coverage for your medication approved through our exceptions process. We are also happy to work with your doctor to determine alternative medications that are covered under our plan that may work well for you, or to answer any questions you may have about the formulary exception process.

Last Updated Date: ​​01/01/2024

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