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2012 Transition Policy for Welborn Health Plans Medicare Advantage Plans

Value Rx (HMO)
Silver Rx (HMO)
Platinum Rx (HMO)
Platinum Select Rx (HMO-POS)

Introduction
Welborn Health Plans (WHP) has the following processes for new and existing members to transition you into the 2012 plan year when you have limited ability to fill your current prescription(s). You may be unable to fill your current prescription(s) if it is not on the plan's formulary; it requires prior authorization due to quantity limits or has step therapy requirements.

Cost Sharing for a Temporary Supply of Drugs Provided Under the Transition Policy
For LIS members the cost-sharing for a temporary supply of drugs provided under this transition process never exceeds the cost-sharing maximum amounts for low- income subsidy (LIS) members. For non- LIS members, the cost-sharing for a temporary supply of drugs provided under this transition process is based on one of the plan's approved cost- sharing tiers and is consistent with cost- sharing under the plan for non- formulary drugs approved under an exception.

One-Time Transition Supply for Retail Pharmacy
In a retail setting, the transition process provides for up to a 30-day supply unless the prescription is written by a doctor for less than 30 days. In this case, multiple fills up to a cumulative 30-day supply are allowed any time during the first 90 days of the member's enrollment in the plan, beginning on the member's enrollment effective date.

Transition Supply for Residents of Long Term Care Facilities
In the long- term care setting, the process provides for (1) a 98-day fill (unless the member has a prescription written for less than 98 days), with multiple refills as necessary, during the first 90 days of the member's enrollment in a plan, beginning on the member's enrollment effective date; and (2) after the 98 day transition period has expired, a 31-day emergency supply of Non-formulary Drugs (unless the member has a prescription written for less than 31 days) while an exception or prior authorization is requested.

Transition Extension
On a case-by-case basis, WHP may provide a 30 day extension of the transition period to accommodate beneficiaries who continue to await resolution of a pending prior authorization or exception request.