Transition process

What is the transition process?

BCBSNC has established a transition process for new enrollees whose current drug therapies are not included in the Blue Medicare Rx formulary. Generally, temporary supplies of noncovered or nonformulary medications are not covered by these plans, but overrides for certain medications can be made during the transition period. The transition medication supply will provide additional time for you to seek a formulary alternative or to complete an exception request.

When does the transition process apply?

A temporary supply of certain noncovered or nonformulary medications may be covered during a transition period for particular scenarios including, but not limited to the following:

• The initial transition of beneficiaries to the Blue Medicare Rx benefit on January 1, 2007
• The transition of new enrollees during the plan year after the initial implementation of the program
• The transition of individuals who change plans during plan enrollment periods
• The transition of enrollees back into their Medicare PDP after having been covered in another setting or under another plan (e.g., individuals who enter long-term care facilities from hospitals or enter an ambulatory setting from a hospital)

How do I get a transition supply of a noncovered medication?

We have already identified a number of nonformulary drugs that qualify for automatic transition supplies. These drugs are for treating conditions where a break in current drug therapy could have an adverse affect on your health. If you are currently taking one of these drugs, the pharmacy will fill your prescription for a one–time, 30–day supply after your Plan effective date. You will receive notification that you were dispensed a noncovered or nonformulary medication and the process that must be followed by your provider to request authorization for continued coverage.

During this 30–day period you will need to:

• Contact your prescribing provider to find out which formulary drugs may be substituted, and/or
• Contact BCBSNC (this contact can be made by you, your authorized representative or your prescribing provider) and request an "Exception." We will make a determination about whether we will cover your drug, even though it is not on the plan formulary.

For residents of long–term care facilities, who are on noncovered medications, we will provide coverage for a temporary "first fill" supply order for at least a 90– to 180–day supply of medication prescribed by the attending physician until an appropriate arrangement can be made between the facility, the attending physician, and the long–term care pharmacy, on behalf of resident.