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The purpose of the policy is to ensure necessary continuity of treatment and to provide adequate time and transition process to introduce the member and their prescribing physician to the Community Care Alliance of Illinois Medicare Formulary.
The following is covered under the Transition Policy:
The policy also describes how transition benefits apply when in the following settings:
Retail and Mail Order: New members or re-enrolled members to the plan may allow you to receive a 30 day transition supply (or greater if the packaging cannot be reduced, or less if the prescription is written for fewer days) of Part D eligible drugs. This can occur at any time within your first 90 days of coverage.
Long Term Care: You may be allowed a 31 day transition supply (unless prescription is written for fewer days) of eligible Part D drugs during the following times:
If you are currently taking drugs that are not listed in the plan’s drug list (formulary) from one year to the next, you may be eligible for a transition fill if the following applies to you:
You can receive eligible Part D drugs under the transition fill when:
Certain drugs may not be eligible for a transition supply at the pharmacy and therefore will require a review to determine if the drugs can be covered under the Part D plan.
We will send written notice via U.S. mail to the member within three business days of adjudication of a temporary fill. The notice will include:
For Long Term Care transition fill for oral brand solids limited to a 14 days’ supply, a Transition Fill notice will be sent only after the first temporary fill.
Level of Care Changes
You may have changes that take you from one level of care setting to another. During the change, drugs may be prescribed that are not covered by the plan. If this happens, you and your doctor must go through the plan’s coverage determination process.
We will use Express Scripts Part D Services, on a case-by-case basis, will provide an extension of the transition period to accommodate members who continue to await resolution of a pending prior authorization or exception request. The extensions are available through the Pharmacy Help Desk or Customer Care and per your plan design.
New Prescription vs Ongoing Drug Therapy
The transition process is setup so that the distinction cannot be made between a brand-new prescriptions for a Non-Formulary Drug or an ongoing prescription for a Non-Formulary Drug at the point of sale, Express Scripts Part D Services, transition process will be applied to the prescription as if it is ongoing drug therapy.
Transition across Contract Years for Current Members
The following processes are options that we may request Express Scripts Part D Services to implement for renewing members:
Treatment for Re-Enrolled Members
You may decide to leave one plan to enroll in a new plan or re-enroll in the original plan you had. If this happens, you would be considered as a new member and therefore eligible for transition benefits.
Call Eon Health’s Member Service department at 1-877-364-4566 (TTY: 711) for more information. From October 1 – March 31, seven days a week, from 8 a.m – 8 p.m and April 1 – September 30, Monday through Friday, from 8 a.m – 8 p.m (you may leave a voicemail Saturday, Sunday and Federal Holidays)
Eon Health has a contract with Medicare to offer HMO and PPO plans. Eon Health also has a contract with the Georgia Medicaid Program and a contract with the South Carolina Medicaid program. Enrollment in Eon Health depends on contract renewal.
Clear Spring Health has a contract with Medicare to offer PPO, HMO, and PDP Plans. Eon Health has a contract with the Georgia Medicaid program and a contract with the South Carolina Medicaid program. Enrollment in these plans depends on contract renewal. Clear Spring Health Deluxe (HMO SNP): This plan is available to anyone who has both Medicare and received assistance from the State. Clear Spring Health Silver (HMO SNP): This plan is available to anyone with Medicare who has been diagnosed with Cardiovascular Disorder, Chronic Heart Failure or Diabetes. Eon Health has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until December 31, 2022 based on a review of Eon Health’s Model of Care. This information is not a complete description of benefits. Contact the plan for more information. Limitations, Copayments, and restrictions may apply. Benefits, formulary, pharmacy/provider network, premium and cost sharing may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Premiums, co-pays/co-insurance may vary based on the level of Extra Help you receive. Please contact the plan for further details. Medicare beneficiaries may also enroll in Eon Health through the CMS Medicare Online Enrollment Center located at www.medicare.gov. The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary. Clear Spring Health Choice (PPO): Out of network/non-contracted providers are under no obligation to treat Eon Health members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask for a pre-service organization determination before you receive the service. Please call our customer service or see your Evidence of Coverage for more information, including cost-sharing that applies to out-of-network services.