Granite Alliance wants to provide you with the highest quality of care. We understand that sometimes you are taking a medication that has different coverage on our formulary. These medications may be non-formulary, have a quantity limit, or require prior authorization or step therapy. In these situations, we have a process that will temporarily allow you to continue receiving the Medications that are covered by Medicare Part D. This will give you time to talk with your prescriber to decide if you should switch to a different medication that is covered on the formulary or submit a request for a coverage determination or exception. The Transition Benefit applies for a 90-day period once certain circumstances occur.
For more information about the Transition Benefit Policy, click here.
For questions regarding your Transition Benefits please contact Member Services.
Member situations that initiate a Transition Benefit:
A new member to Medicare or the Plan
Members who reside in a Long Term Care (LTC) facility
Admission to or discharge from an LTC facility
Discharge from a hospital
End of stay at a skill nursing facility covered under Medicare Part A (including pharmacy charges), and revert to a coverage under Part D
Revert from hospice status to a standard Medicare Part A and B benefits
Discharge from a psychiatric hospital with highly individualized medication regiments
Members affected by certain formulary changes- Whenever a medication is removed from the formulary, if you were receiving the medication prior to the change you will be provided a transition benefit
Transition Benefit Period
Outpatient Retail or Mail Order
Members are entitled to an accumulated 30-day supply, within the 90-day transition period. If the prescription was written or filled for less than a 30-day supply, multiple fills are allowed until the member receives an accumulated 30-day supply.
Inpatient Long Term Care
Members are entitled to an accumulated 30-day supply, within the 90-day transition period. Each fill cannot exceed a 30-day supply and are subject to short-cycle dispensing requirements. If the prescription was written or filled for less than a 30-day supply, multiple fills are allowed until the member receives an accumulated 30-day supply.
Long Term Care transition benefits can be allowed up to a 30-day supply to be consistent with dispensing increments.
Members in an LTC are entitled to a 31-day emergency supply of non-formulary medication for Part D medication while a request for an exception or prior authorization is being requested and reviewed. If the prescription was written or filled for less than a 31-day supply, multiple fills are allowed until the member receives an accumulated 31-day supply.
Emergency supplies may occur at any time while in an LTC and are not subject to the transition benefit period.
Notification of Transition Benefit
Members will receive a transition letter in the mail once a transition benefit has been used. The letter will include:
An explanation of the transition benefit
Instructions on how to work with the prescriber to decide if the member should switch to a different medication that is covered on the formulary
Instructions on how to request a coverage determination
Explanation of the member's rights to request an exception and instructions on how to submit
A transition notification letter will also be sent to the prescriber.
Terms and Definitions
A temporary supply of medication
A preferred list of medications covered by the plan
A mediation that is not covered on the Formulary
An approval from Granite Alliance before the prescription will be covered
Requirement of trial/failure of another specific medication(s) for a certain length of time before the coverage of the medication
A request to cover and provide for a medication that is formulary which has edits, such as Prior authorization, Step therapy, Quantity Limits
A request to cover and provide a non-formulary medication
Long Term Care - care that helps with the activities of daily life, like eating, dressing or bathing, over a long period of time