Prescription Drug Transition Process

When you first join Security Health Plan, you might be taking a medication that is not on our formulary or one that is on our formulary, but normally requires prior authorization (PA), step therapy (ST) or has a quantity limit (QL). Our Prescription Drug Transition process allows time for you to work with your health care provider to switch to a therapeutically appropriate formulary alternative or to request a coverage determination.

Here’s how it works

Within the first 90 days of your enrollment, Security Health Plan provides a transition supply of medications that are not on formulary or normally require prior authorization, step therapy or a quantity limit exception.  The transition fill will be for up to a 34-day supply (or less, if your prescription is written for less), whether at a retail pharmacy or if you are a resident in a long-term care facility.

Other times when you will benefit from the Prescription Drug Transition Process

There are times outside of the first 90 days of your enrollment when the Prescription Drug Transition process applies. One of the more common examples is when you experience a change in level of care (for example, discharged from a hospital to your home or a long-term care facility, or if you end a long-term care stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in level of care.

Additionally, for members in a long-term care facility, Security Health Plan will cover at least a 34-day emergency supply of newly prescribed medications (those not on the formulary, normally require a prior authorization, step therapy or have a quantity limit) while a coverage determination is requested. This coverage is offered at any time during your membership, not just during the first 90 days.

In some situations, current members could be affected by formulary changes that occur mid-year. If such changes occur, you will be notified at least 30 days in advance. The advance notice provides sufficient time for you to work with your health care provider to switch to a therapeutically appropriate formulary alternative or to request a coverage determination.

You will be notified

If you are in any of the situations described above and receive a transition supply of medication, we will send you a letter within three business days notifying you that the supply you received is temporary. The letter will explain the temporary nature of the transition supply and how you and your prescriber can work with Security Health Plan to switch to an appropriate therapeutic formulary alternative. It will also explain your rights to request a coverage determination and what to do if you need to continue on your original medication or receive the quantity prescribed by your provider.

Please remember

Please note that our transition policy applies only to those drugs that are “Part D eligible.” It cannot be used to get coverage for a non-Part D drug. Benefits are only available at network pharmacies except under non-routine circumstances when a network pharmacy cannot be reasonably used. Network pharmacies include designated retail, chain, mail order, long-term care, home infusion and Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) pharmacies. Call Security Health Plan  Customer Service for more information.