The outpatient pharmacy setting includes retail, home infusion, mail order and safety net as well as Indian Health Service and Tribal/Urban Indian Health pharmacies. A temporary, 30-day supply (unless the prescription is written for less than a 30-day supply) of drugs not included on our list of covered drugs will be provided anytime during the 90-day transition period.
Transition Policy
We provide a transition process consistent with the Centers for Medicare and Medicaid Services (CMS) policy, which deals with access to covered prescription drugs under Medicare Part D.
The process includes a written description of how enrollees whose current drug therapies may not be included in the 2026 HAP covered drug list (also known as a formulary) may receive a temporary supply of a non-formulary drug. The process also describes Part D drugs that are on the formulary but require prior authorization, step therapy or are subject to quantity limits under the HAP Medicare utilization management rules.
A meaningful transition period allows sufficient time for members to work with their healthcare provider to select an appropriate formulary alternative or to request a formulary exception based on medical necessity.
Transition policy eligibility
The transition policy applies to:
- New enrollees into prescription drug plans at the beginning of a contract year
- The transition of newly eligible Medicare beneficiaries from other coverage at the beginning of a contract year
- The transition of individuals who switch from one plan to another after the beginning of a contract year
- Enrollees residing in long-term care facilities
- Current enrollees affected by formulary changes from one contract year to the next
Transition policy facts
The following information applies to members who make use of our transition policy:
If you need a medication that isn’t on the plan’s list (non-formulary), you can get a temporary supply for 31 days (or less if your prescription is for less) during the 90-day transition period. This supply can be given in parts (incrementally) and refilled as needed during the first 90 days after your coverage starts.
The Centers for Medicare and Medicaid Services (CMS) defines an emergency transition supply as a one-time fill of a non-formulary drug, or a drug not on the covered drug list, necessary with respect to current members in the long-term care setting, and will be provided to current long-term care enrollees who enter into a facility from another care setting.
We’ve authorized our claims processor to place a manual override at the point of sale to accommodate a one-time (up to 31 days) fill in this scenario.
The Centers for Medicare and Medicaid Services (CMS) transition guidance requires that current members affected by a negative change to the covered drug list across contract years be provided with a transition process consistent with the transition process required for new enrollees.
We allow current members to access transition supplies when their claims history from the previous calendar year contains an approved claim for the same drug that the member is attempting to fill through transition.
Situations may exist in which a member’s transition period may need to be extended, on a case-by-case basis, such as when the member's exception request or appeal hasn’t been processed by the end of the minimum transition period and until such time as a transition has been made.
In these situations, we may extend the member’s transition period in order to provide continued coverage of the transition drug.
For low-income subsidy (LIS) eligible beneficiaries, the cost-sharing amount applied doesn’t exceed the statutory maximum copayment amounts. For non-LIS members filling drugs not on our covered drug list, the cost-sharing amount applied during claims adjudication will be consistent with the plan’s approved cost-sharing tiers for drugs not on our covered drug list.
Additionally, for non-LIS members filling drugs on our covered drug list with utilization management requirements, the cost-sharing amount applied during claims adjudication is the cost associated with the plan’s assigned drug list tier.
Per Centers for Medicare and Medicaid Services (CMS) guidance, members in transition while taking a drug within a protected drug class must be granted continued coverage of therapy for the duration of treatment, up to the full duration of active enrollment in the plan. Prior authorization and step therapy restrictions, which may apply to new members who have never taken a particular drug, aren’t applied to those members transitioning to the Medicare Part D plan on agents within these key drug classes.
There are six protected classes of medications:
- Antidepressants
- Antipsychotics
- Anticonvulsants
- Antineoplastics, which affect the process of cell division
- Antiretrovirals, which doctors use to treat retroviruses
- Immunosuppressants, to prevent organ transplant rejection
Transition fill notification occurs in two ways. We notify the pharmacy at the time of our decision with information that the pharmacist may give to the member regarding the status of the particular drug not on our covered drug list or drug with utilization management. The transition information goes to pharmacies in a retail setting (including home infusion, safety net and Indian Health Service/Tribal/Urban Indian Health) as well as pharmacies in a long-term care setting.
Or we send written notice via U.S. First-Class Mail to a member and the prescriber within three business days of our decision regarding a temporary fill. The notice will include:
- An explanation of the temporary nature of the transition supply the member has received
- Instructions for working with the plan sponsor and the member’s prescriber to identify appropriate therapeutic alternatives that are on the plan’s covered drug list
- An explanation of the member’s right to request an exception to our covered drug list requirements
- A description of the procedures for requesting an exception to our covered drug list requirements
A formulary exception form is available for members, their appointed representatives and doctors. This form may be submitted by mail, fax, the HAP member portal or email.
Health Alliance Plan
Attn: Pharmacy Care Management
1414 E Maple Rd
Troy, MI 48083
Fax
(313) 664-8045
Health Alliance Plan (HAP) has HMO, HMO C-SNP, HMO-POS, and PPO plans with Medicare contracts. HAP Medicare Complete Duals (HMO D-SNP), HAP Medicare Complete Assist (PPO D-SNP), and HAP CareSourceTM MI Coordinated Health (HMO D-SNP) are Medicare health plans with a Medicare contract and a contract with the Michigan Medicaid Program that provides benefits of both programs to enrollees. Enrollment depends on contract renewals.