Physicians Health Choice Part D Transition Policy

If you are a new member to Physicians Health Choice, you may be taking prescription drugs that aren't on our formulary or subject to certain restrictions- such as quantity limits, prior-authorization or step-therapy requirements. To ensure a smooth transition process for individuals who are joining Physicians Health Choice from another Part D plan, Physicians Health Choice has established a transition process to address these needs within the first 90 days of membership. In some cases, current enrollees may be affected by formulary changes from one contract year to the next.

Transition Policy

Physicians Health Choice's transition policy addresses situations in which new members may or may not be aware of the medications that are on Physicians Health Choice's formulary, unsure what is covered on Physicians Health Choice's formulary or unfamiliar with Physicians Health Choice's formulary exception process. The transition policy meets the immediate needs of our members and allows the member sufficient time to work with their prescribing physician to switch to a therapeutically equivalent formulary medication or complete the formulary exception process.

When a new member goes to a network pharmacy and we provide a temporary supply of a Part D drug that isn't on our formulary, or that has coverage restrictions or limits- we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. After we cover your temporary supply, we'll send you a written notice that will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term-care (LTC) facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan.

If a LTC enrollee is outside his or her 90-day transition period, Physicians Health Choice will provide an emergency supply of non-formulary medication (including Part D medications that are on Physicians Health Choice's formulary but require prior authorization or step therapy under Physicians Health Choice's utilization management rules). This emergency supply will be for at least 31 days of medication, unless the prescription is written for less than 31 days. The emergency supply is to ensure that members receive their medications while an exception has been requested through Physicians Health Choice.

Level of Care Changes

Members may experience unplanned level of care changes (i.e. discharged or admitted to a LTC facility, hospital, nursing facility skill level change). In these circumstances, Physicians Health Choice will provide a one-time temporary fill for a level of care change. This fill will be authorized for up to a maximum of 30 days supply (unless the prescription is written by the physician for less than 31 days of medication).

Transition Notification

All members who receive a temporary supply of a non-formulary Part D medication will receive a written notice in the mail regarding their transition fill and the transition process. This notification will be sent within 3 business days of the temporary fill. The notice will include: (1) an explanation of the transition supply that you received; (2) instructions for working with Physicians Health Choice and the your prescriber to identify appropriate therapeutic formulary alternatives; (3) an explanation of your right to request a formulary exception; and (4) a description of the formulary exception process.

Formulary exception requests will be available to both members, appointed representatives, and physicians via mail, fax and through the Prescription Drugs section of our Web site.

Please note that our transition policy applies only to those drugs that are "Part D drugs". The transition policy can't be used to buy a non-Part D drug. See your Evidence of Coverage for information about non-Part D drugs, or call Customer Service at 1-866-550-4736 (TTY/TDD users may call 711) from 8 am - 8 pm, Monday through Friday.