Medicine Transition Policy

There may be times when CareAdvantage does not cover a drug that your doctor prescribed. However, you may still be able to get that drug by asking CareAdvantage to cover it. Below are some of the reasons a drug may not be covered, and instructions on how to request coverage under these circumstances.  

Transition Coverage

If you are new to CareAdvantage, the drug you have been taking may not be in our formulary. You may be able to get one temporary refill of that drug during the first three months of your enrollment in CareAdvantage. The refill can be for a supply of up to 30 days. CareAdvantage will not pay for a second refill.

You can contact the CareAdvantage Unit if you have any questions about transition coverage.

Members in Long-term Care

• If you are a new member of CareAdvantage while a resident at a long-term care facility, we will cover a supply of your drug during the first 90 days of your membership in the plan. The supply of drug that you may receive is up to a 30-day supply. If your doctor prescribes less than a 30-day supply, you may receive multiple fills until you receive a total supply of up to 30 days.
• If you have been a CareAdvantage member for more than 90 days and live in a long-term care facility and need a supply right away, we will cover one 31-day supply, or less if your prescription is written for fewer days.
• If you are transitioning between different levels of care (for example, into or out of a long-term care facility or hospital) and you have recently filled a prescription for a new drug, we will cover a new 30-day supply of the drug for you to use in your new setting. This will take care of any restrictions that could exist due to refilling your prescription too soon.

You can contact the CareAdvantage Unit if you have any questions about transition coverage.

Transition Coverage Options

If you get a temporary refill for a drug that is not covered, you need to decide what to do after you finish your refill. Your prescribing doctor can help you decide. You have two options:

• Your doctor can prescribe a drug that is in the CareAdvantage Formulary that treats the same condition as the one you have been taking.
• Your doctor can ask for a formulary exception. To do this, they must submit, in writing, the medical reason that HPSM should continue to cover a drug that is not in the CareAdvantage Formulary beyond the 30-day supply. Your doctor can send this reason to HPSM using our CareAdvantage Determination Request Form. We send this form to you and your doctor with a letter when we pay a transition claim. Your doctor can also request a formulary exception in the form of a letter or over the phone by calling HPSM Pharmacy Services at 650-616-2088.

Drugs Excluded from Transition Coverage

CareAdvantage covers only Medicare Part D drugs in the Drug Transition Period. Prescriptions filled at pharmacies outside of the CareAdvantage network will only be covered in situations that qualify for out of network coverage.

Formulary exceptions

CareAdvantage has rules about who is eligible to get which medicines. For example:

• CareAdvantage may cover the medicine your doctor prescribed, but you may not meet the coverage criteria.
• CareAdvantage may no longer cover a medicine you have been taking due to a formulary change.

CareAdvantage sometimes makes exceptions to the rules if the prescribing doctor shows there is a medical reason that a person needs a particular medicine. This is called a formulary exception.

Request a formulary exception

To request a formulary exception, your doctor should contact HPSM Pharmacy Services at 650-616-2088, then fax a written statement to 650-829-2045 that explains the medical reason for this request.