Drug Transition Policy

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Community Advantage Plus (HMO D-SNP), a Medicare and Medi-Cal Plan, Transition Policy

When you join Community Advantage Plus, you may already be using medications that are either not listed on our formulary or come with certain requirements such as prior authorization or step therapy. In addition, members who continue their coverage may be affected by formulary updates from year to year. In these cases, you can work with your doctor to determine if switching to a drug on the formulary is appropriate, or you may request a formulary exception (coverage determination) to continue receiving your medication.

For full details on requesting an exception, please see Chapter 9 of your Member Handbook or call Member Services at 1-888-484-1412 (TTY: 711)

Who qualifies?

During the first 90 days after enrollment or a change in coverage, Community Advantage Plus may provide a temporary supply of medication for:

• Members whose prescriptions are affected by updates to the list of covered drugs
• New members who enroll with Community Health Plan of Imperial Valley (CHPIV) following the annual election period
• Individuals who are newly eligible and transferring from another health plan
• Members switching between health plans mid-year
• Existing members whose medications are impacted by formulary changes
• Members living in long-term care (LTC) facilities

Picking up prescriptions

If you go to a network pharmacy and receive a temporary supply of a medication that is not on the formulary—or has restrictions such as prior authorization or step therapy—Community Advantage Plus will cover up to a 31-day supply (unless your prescription is written for fewer days).

After this temporary fill, these drugs are generally not covered again under the transition policy. You will receive a written notice explaining the next steps, including how to request a formulary exception and how to coordinate with your provider to select an alternative drug that is covered.

Long Term Care

For members who live in a long-term care facility, Community Advantage Plus will provide a 31-day transition supply (unless prescribed for fewer days). If needed, additional refills may be covered during the first 90 days of your enrollment.If you have been a member for more than 90 days and still require a non-formulary drug or a drug with restrictions, we will cover a temporary 31-day emergency supply while you pursue an exception request.

Change in Level of Care

If your care setting changes (for example, being discharged from a hospital to a nursing facility or to your home), Community Advantage Plus will provide a temporary fill of non-formulary or restricted drugs. We will make coverage determinations as quickly as your condition requires.

Requesting a Temporary Supply

To request a temporary supply, call Member Services at 1-888-484-1412 (TTY: 711). Our team is available 24 hours a day, 7 days a week. The call is free.

Additional Information

Please note: The List of Covered Drugs and the pharmacy and provider networks may change throughout the year. You will receive advance notice before any change that affects your coverage.