CareSource Plan Transition Process – Part D Drugs

Transition Process (updated 01/6/2010)

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 90 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 90 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 90-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs 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 drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

As a continuing member in the Plan, you may notice that a formulary medication which you are currently taking is either not on the upcoming year’s formulary or its cost-sharing or coverage is limited in the upcoming year.

In this case, we will provide for a transition period consistent with the above transition process for new enrollees. You may contact us and we will tell you the names of the covered drugs that are also used to treat your condition so you can talk to your provider to see if any of these drugs are an option for your treatment.