A Healthy CollaborationSM

Transition Policy

TexanPlus® Transition Policy for Medicare Advantage Prescription Drug Coverage

The TexanPlus transition policy varies depending upon your status as a new or existing member.

New Members
As a new member to our plan, you may be taking medicines that are not on our formulary (the list of drugs covered by TexanPlus), or drugs that are covered but whose cost sharing or coverage is limited. In this case, you need to talk with your doctor about alternatives available on our formulary. If there are no alternatives on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to receive the medicine you are taking for a period of time specified in the approval letter. While you and your doctor are determining the best course of action, you may be eligible to receive a 30-day* transition supply of the medicine anytime during your first 90 days as a member of our plan.

For more information on how to request a formulary exception, visit the Exceptions, Appeals and Grievances page.

For each medicine of yours that is not on our formulary or has limited cost sharing or coverage, we will cover a temporary 30-day supply* if you go to a network pharmacy. After your first 30-day transition supply, we may not continue to pay for these medicines under the coverage transition policy. You are reminded to discuss with your doctor appropriate alternatives on our formulary. If there are none, you or your doctor can request a formulary exception.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply of your medicines.* We will also cover more than one refill of these medicines for the first 90 days you are a member of our plan. If you need a medicine that is not on our formulary or its cost sharing or coverage 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 medicine* while you pursue a formulary exception.

Continuing Members
If you are already a TexanPlus member, you will receive your Annual Notice of Change (ANOC) by October 31st. You may notice that a medicine you currently take is either not on the upcoming year's formulary or has limited coverage. If this happens, you must work with your doctor to either find an appropriate alternative on our new formulary or request a formulary exception prior to the beginning of the New Year. If the exception request is approved, we will authorize payment prior to January 1st and provide coverage beginning January 1st.

As a continuing TexanPlus member, we will also cover a temporary transition supply of medicine if you have a level of care change. This may include unplanned changes in treatment settings, such as being discharged from an acute care (hospital) setting or being admitted to or discharged from a long-term care facility. We will cover up to a temporary 30-day supply or a 31-day supply for residents of long-term care facilities* for each of your medicines that is not on our formulary, or whose cost sharing or coverage is limited, when you go to a network pharmacy.

If you have any questions about our transition policy or need help asking for a formulary exception, please call Member Services at 1-866-230-2513 (TTY/TDD users call 1-866-338-4681) from 8 AM to 8 PM, 7 days a week.

* Unless your prescription is written for fewer than 30 days.

M0018_H4506_webr6_1209 Pending CMS Approval Last updated: 1/11/2021

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