Drug Transition Policy
CommuniCare Advantage (HMO D-SNP), a Medicare Medi-Cal Plan, Transition Policy
When you become a member of CommuniCare Advantage, 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. Current members may also be impacted by changes in our formulary from one year to the next. You may speak to your doctor to help you decide if you should switch to an appropriate drug that is covered by CommuniCare Advantage or request a formulary exception (coverage determination) in order to get coverage for the drug.
You may refer to Chapter 9 in your Member Handbook to learn more about how to request an exception. You may also call Member Services if:
your drug is not currently on our formulary;
your drug is subject to certain restrictions, such as prior authorization or step therapy;
your drug will no longer be on our formulary next year and you need help switching to a different drug that is covered; or
you need help requesting a formulary exception.
CommuniCare Advantage may provide a temporary supply of the non-formulary drug if you need a refill of the drug during the first 90 days of new membership in our plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the drug if you need a refill of the drug during the first 90 days of the new plan year. During this time period you should speak to your doctor to determine the right course of action.
When you go to a network pharmacy and CommuniCare Advantage provides a temporary supply of a drug that is not covered on our formulary, or that has coverage restrictions or limits (but is otherwise a considered a “Part D drug”) , we will cover a 31-day supply (unless the prescription is written for fewer days). After CommuniCare Advantage covers the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. CommuniCare Advantage will provide you with a written notice after we cover your temporary supply. The notice will provide explanation of the steps you can take to request an exception and how to work with your provider to decide if you should switch to an appropriate drug that is covered by CommuniCare Advantage.
If you are a new member that resides in a long-term-care facility (such as a nursing home), CommuniCare Advantage will cover a 31-day transition supply (unless the prescription is written for fewer days). If necessary, CommuniCare Advantage will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our plan. If you have been enrolled in our plan for more than 90 days and need a drug that is not on our formulary or is subject to certain restrictions, such as prior authorization or step therapy, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.
We will also provide a temporary fill when you experience a change in the level of care you receive, for example, when you are discharged from the hospital to a long-term care facility or home. We will make coverage determinations and re-determinations as soon as your health condition requires. You will be provided with an emergency supply of non-formulary drugs, including drugs that are subject to certain restrictions, such as prior authorization or step therapy.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
CommuniCare Advantage (HMOD-SNP) is an HMO D-SNP health plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in CommuniCare Advantage depends on contract renewal.
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Last Website Update 09/14/2023