Part D Transition Guidelines
WellCare has established a process to address the needs of individuals who are joining WellCare from other Medicare Part D providers and ensure a smooth transition process for WellCare members. Our transition guidelines specifically address:
- New members on January 1 following the Annual Election Period
- Newly eligible people with Medicare
- Existing members impacted by a negative formulary change from the prior year
- Members who may switch Medicare Part D plans after January 1
- Members who may reside in long-term care (LTC) facilities
WellCare's transition policy applies to:
- Part D medications that are not on WellCare's formulary
- Part D medications that are on WellCare's formulary but may require prior authorization or step therapy under WellCare's established utilization management rules.
WellCare has created a Pharmacy and Therapeutics (P&T) committee comprised of both pharmacists and physicians from many fields (e.g. Internal Medicine, Psychiatry, etc.). Our P&T committee reviews and provides recommendations regarding non-formulary medication requests. Also, our P&T committee establishes protocols for suggestions to both Medicare Part D enrollees and their physicians’ use of therapeutically formulary alternatives.
WellCare's transition policy addresses those situations in which members may or may not be aware of the medications that are on WellCare's formulary, are unsure what is covered by WellCare's formulary, or are unfamiliar with WellCare’s formulary exception process. WellCare's transition policy meets the immediate needs of our valued members. The policy allows the member sufficient time to work with his or her prescribing physician to switch to a therapeutically equivalent formulary medication or complete the formulary exception process.
Ambulatory (Community) Members
During the member's first 90 days of enrollment with WellCare, the member can obtain up to a 30-day temporary supply of a non-formulary medication (including Part D drugs that require a prior authorization or step therapy).
Long-Term Care (LTC) Members
During the member's first 90 days of enrollment with WellCare, the member can obtain up to a 31-day transition supply. WellCare will honor multiple fills up to a total of a month’s supply of non-formulary Part D medications (including Part D medication that are on WellCare’s formulary but require prior authorization or step therapy under WellCare's utilization management rules) as appropriate during the 90-day transition period.
If an LTC enrollee is outside his or her 90-day transition period, WellCare will provide an emergency supply of non-formulary medication (including Part D medications that are on WellCare's formulary but require prior authorization or step therapy under WellCare’s utilization management rules). This emergency supply will be for at least a 31 days’ supply 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 WellCare.
There are times when a beneficiary may experience an unplanned level of care change transition (e.g.; discharged or admitted to an LTC facility, discharged or admitted to hospitals, nursing facility skill level changes, etc.). In these instances, WellCare will provide an emergency supply of non-formulary medication (including Part D medications that are on WellCare's formulary but require prior authorization or step therapy under WellCare'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 WellCare.
The exception to the 31-day fill limit is the Part D short cycle dispensing program. If the medication qualifies for short cycle dispensing (generally a brand drug dispensed in an LTC setting), the claim will be payable up to a 14-day supply.
Negative Formulary Changes
WellCare understands that some members who continue as WellCare members into the next year may be impacted by negative formulary changes that occur to WellCare's Medicare formulary annually. Even though members are sent an Annual Notice of Change (ANOC), WellCare realizes that not all members may be aware that some medications that are considered formulary in the previous year may be considered non-formulary in next year. To help alleviate some of this confusion, WellCare allows a transitional fill, for a maximum of 30 days of medication, of all medications that are impacted by negative formulary changes in the new year as long as the member had received the medication within the last 180 days of the prior year. If the prescription is written by the prescriber for less than a 30-days supply, the prescribed days’ supply defines the minimum quantity authorized as the transition fill. Long term care members will receive a 31-day fill, with multiple refills as necessary for 90 days.
Transition Fill Requests Due to Other Reasons and Extension of Transitional Fills
WellCare continues to provide necessary Part D drugs to members via an extension of the transition period, on a case-by-case basis, to the extent that their exception request or appeal has not been processed by the end of the minimum transition period and until such time as a transition has been made (either through a switch to an appropriate formulary drug or a decision on an exception request).
All members who receive a temporary supply, as well as the prescribing physician, of a non-formulary Part D medication will receive a written notice via U.S. First-Class Mail regarding their transition fill and the transition process. This notification will be sent within 3 business days of adjudication of a temporary transition fill. The notice will include:
- An explanation of the transition supply that the member received;
- Instructions for working with WellCare and the member's prescriber to identify appropriate therapeutic formulary alternatives;
- An explanation of the member's right to request a formulary exception; and
- A description of the formulary exception process.
Formulary exception requests will be available to members, their prescribing physicians (or other providers), and/or their representatives via fax, mail, email, and online via the plan’s web sites.