How can I find the status of a coverage request or Prior Authorization for my patients?

There are three different ways to access this information.

  1. Visit the Prior Authorization Status Search page,
  2. Call our automated service at 1-866-316-6049,
  3. Check your Fax machine each morning. During evening hours, we Fax pharmacies and doctor’s offices with lists that indicate the status of outstanding Prior Authorization requests. All requests will be listed by member as either approved, denied or in process.
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How can I find formulary alternatives?

Use the Drug Search Tool to search for a specific prescription drug to find out if it is covered and to view suggestions for Formulary Alternatives. You can also contact us by calling toll free 1-866-693-4620, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) 7 days a week.

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What is a Transition Supply?

A Transition Supply is a limited supply of a Part D drug that is either not on a plan’s formulary or is covered but is subject to a utilization management restriction, such as Prior Authorization or Step Therapy under the plan’s utilization management rules.  Transition Supplies are intended to enable eligible Part D enrollees sufficient time to work with their health care providers to change to a formulary alternative or request a formulary exception.

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Who is eligible for a Transition Supply?

Members eligible for a Transition Supply include:

  • Newly-enrolled Prescription Drug Plan members at the beginning of the contract year
  • Members who switch from one plan to another after the contract year begins
  • Members who reside in long-term care (LTC) facilities
  • Existing members who have an unplanned transition and change treatment settings due to a change in their level of care
  • In some cases, current members affected by formulary changes from one contract year to the next.

For more information about the Transition Policy go to the Search Formularies, Prior Authorization and Exception forms page.

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What is the new member Transition Supply?

New members are eligible to receive the following Transition Supplies anytime during the first 90 days of their plan enrollment:

  • Outpatient setting: A one-time, temporary 30-day supply is provided (unless the prescription is written for less than 30 days). Multiple refills will be allowed as necessary, up to a total 30-day transition supply.
  • Long-term care (LTC) setting: A temporary 34-day supply is provided (unless the prescription is written for less than 34 days). Multiple refills will be allowed as necessary, up to at least a total 91-day transition supply (for a 7-day dispensing increment) and up to a 98-day transition supply (for a 14-day dispensing increment), consistent with the dispensing increment.

Transition extensions are considered on a case-by-case basis.

For more information about the Transition Policy go to the Search Formularies, Prior Authorization and Exception forms page.

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How will I know if a patient is eligible for a Transition Supply?

Transition supplies will process automatically at the point of sale. If the adjudication system determines that a member is eligible for a Transition Supply (at retail or long-term care), the claim is automatically paid.

Please note that claims will reject if the submitted quantity is greater than remaining transition fill days supply. An "AG" reject and the following message "MAX DAYS SUPPLY ALLOWED IS XX" indicates the claim must be resubmitted with reduced quantity and days supply.

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What if my patient has an unplanned transition and changes treatment settings due to a change in their level of care?

A Transition Supply is authorized for members who have a level of care change, defined as when a member:

  • Is discharged from a hospital to a home
  • Enters a Long Term Care (LTC) facility from a hospital or other setting
  • Leaves a Long Term Care facility and returns to the community
  • Completes a stay at a Skilled Nursing Facility (SNF) that is covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Medicare Part D plan formulary
  • Reverts from hospice status to standard Medicare Part A and B benefits
  • Is discharged from a psychiatric hospital with medication regimens that are highly individualized

For members who do not reside in a Long Term Care facility (non-LTC members)
Pharmacies must contact Pharmacy Services to obtain Transition Supplies when non-LTC members experience an unplanned change in level of care.

For members recently admitted into a Long Term Care facility (new LTC admissions)
Pharmacies must include automated reason-for-service codes when submitting transition fill claims in order to override "refill-too-soon" rejects. This will also allow for a 34-day supply with multiple fills if needed.

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What if my long-term care patient needs an emergency supply?

Members in a Long Term Care setting are permitted an emergency Transition Supply ("first fill") after the 90-day transition period has expired while an Exception or Prior Authorization is requested. Up to a 34 day prescription will be authorized (unless the prescription is written for less than 34 days). Automated submission clarification codes are submitted by the pharmacy to allow up to a 34-day supply.

For assistance, contact Pharmacy Services toll free at 1-866-693-4620 8:00 a.m. to 8:00 p.m. in your local time zone, 7 days a week.

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How can I help my patient through the Transition Process?

It is important that pharmacies inform members and/or prescribers of the temporary nature of the transition or emergency supply at the point of dispensing. Pharmacists may also assist members submitting an Exception request or changing to a formulary alternative.

Available resources to help you assist your patients:

  • Use the Drug Search Tool to access Formulary alternatives, as well as Exception and Prior Authorization forms and criteria.
  • Call the automated IVR at 1-866-316-6049 to check the status of a submitted Exception request.
  • Use the Prior Authorization Status Search to check the status of a submitted Exception request.

For more information about the Transition Policy go to the Search Formularies, Prior Authorization and Exception forms page.

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Who can I contact to discuss a question about a payment or remittance?

A Customer Service representative will be glad to assist you. Call us toll free at 1-866-693-4620, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351), 7 days a week.

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What is Payer Information?

Please see the Payer Sheet located in the 2012 Pharmacy Communications section.

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How can my patient apply for Extra Help from Medicare?

Medicare’s Extra Help program helps your eligible patients pay for their Medicare Part D Prescription Drug Plan costs. Many people with Medicare qualify for Extra Help assistance and don’t even know it. Your patients can find out if they are eligible for Extra Help by contacting any of these resources:

  • 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week.
  • The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday (TTY users should call 1-800-325-0778) or
  • The State Medicaid Office

Note: People with Medicare who are also eligible for Medicaid automatically receive Extra Help.

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What are the timeframes for Coverage Determinations, including Exceptions and Prior Authorizations?

  • Exceptions: Exception decisions are made within 72 hours of receiving your prescribing doctor’s supporting statement. You may request an “expedited” exception if you or your doctor believe your health could be jeopardized by waiting up to 72 hours. If we allow your request to expedite, you will receive our decision within 24 hours of receiving your prescribing doctor’s statement.
  • Prior Authorizations: Prior Authorization decisions are made within 72 hours of receiving your request.  You may request an “expedited” Prior Authorization if you or your doctor believe your health could be jeopardized by waiting up to 72 hours. If we allow your request to expedite, you will receive our decision within 24 hours of receiving your request.
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What is the timeframe for a Redetermination request?

  • Redeterminations: Redetermination decisions are made within seven days of receiving your request for a standard appeal. You may request an “expedited” appeal if your health requires an answer sooner than seven days. If we allow your request to expedite, you will receive our decision within 72 hours of receiving your request.
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Who can request a Coverage Determination or Redetermination?

A member, a member’s authorized representative or a member’s doctor or other prescriber can request a Coverage Determination or Redetermination.

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