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Drug transition policy & process

New members in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) may be taking drugs that are not on our Drug List. Or they may be subjected to certain rules, such as prior authorization or step therapy. Current members may also be affected by changes to our Drug List from one year to the next.

In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

How can you get a temporary supply of a drug?

To get a temporary supply of a drug, you must meet the two rules below:

  1. The drug you have been taking:
    • is no longer on our Drug List, or
    • was never on our Drug List, or
    • is now limited in some way.
  2. You must be in one of these situations:
    • You were in the plan last year.
      • We will cover a temporary supply of your drug during the first 90 days of the calendar year.
      • This temporary supply will be for up to a 31-day supply.
      • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. You must fill the prescription at a network pharmacy.​
    • You are new to our plan.
      • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan.
      • This temporary supply will be for up to a 31-day supply.
      • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. You must fill the prescription at a network pharmacy. 
    • You have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away.
      • We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above temporary supply.
      • If you are transitioning between different levels of care (for example, into or out of a long-term care facility or a hospital), SCFHP will cover a one-month transition supply of the drug for you to use in your new setting. This will take care of any restrictions that may exist due to refilling your prescription too soon.
      • To ask for a temporary supply of a drug, call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. 

What do you do about a long-term supply?

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:

  • You can change to another drug.
    • There may be a different drug covered by our plan that works for you. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. The Drug List is also available on our website in Member Materials. The list can help your provider find a covered drug that might work for you.

OR

  • You can ask for an exception.
    • You and your provider can ask us to make an exception. For example, you can ask us to cover a drug even though it is not on the Drug List. Or you can ask us to cover the drug above what we limit

To learn more about asking for an exception, see Chapter 9, Section 6.3 of the Member Handbook. Find a copy of the Member Handbook in Member Materials.

If you need help asking for an exception, you can contact Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

To learn more about asking for a coverage decision, such as an exception, click here.

What if there are changes in coverage for your drugs?

Most changes in drug coverage happen on January 1. However, we might make changes to the Drug List during the year. We will send you a notice before we make a change that affects you.

Generally, the Drug List will only change if:

  • A cheaper drug comes along that works as well as a drug on the Drug List now.
  • We learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

  • Decide to require or not require prior approval for a drug. (Prior approval is permission from SCFHP Cal MediConnect before you can get a drug.)
  • Add or change the amount of a drug you can get (called “quantity limits”).
  • Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, please see the Cal MediConnect List of Covered Drugs (Formulary) in Member Materials.

If any of the changes below affect a drug you are taking, the change will not affect you until January 1 of the next year:

  • We move your drug into a higher cost-sharing tier.
  • We put a new limit on your use of the drug.
  • We remove your drug from the Drug List, but not because of a recall or because a new generic drug has replaced it.

In the following cases, you will be affected by the coverage change before January 1:

  • If a brand name drug you are taking is replaced by a new generic drug, we may make this change right away.
    • We may not tell you in advance before we make that change—even if you are currently taking the brand name drug.
    • If you are taking the brand name drug at the time we make the change, we will provide you with information about the specific change(s) we made. You may not get this notice before we make the change.
    • You and your provider can ask us to continue covering the brand-name drug for you. To learn how, please see the Cal MediConnect List of Covered Drugs (Formulary) in Member Materials
  • If a drug is recalled because it is found to be unsafe or for other reasons, we will remove the drug from the Drug List. We will tell you about this change right away.
    • Your provider will also know about this change. He or she can work with you to find another drug for your condition.

If there is a change to coverage for a drug you are taking, we will send you a notice. Normally we will let you know at least 60 days before the change.

Accessibility

You can ask for published materials for free in other formats, such as large print, braille, or audio. Call Customer Service for help.

If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) depends on contract renewal.

Last updated 01/08/2020

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