Understanding the Transition Process
As a new member to the Gold Kidney Health Plan, you may be taking drugs that are not on our drug list or taking drugs that are on our drug list but have a restriction (e.g., prior authorization, quantity limit, step therapy). The transition process allows you to receive a limited supply to give you time to work with your doctor to find a drug alternative, get a prior authorization or request a formulary exception.
While you are talking with your doctor you may be eligible to receive a 30-day transition supply of the drug during the first 90 days you are a member of our plan. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy.
Who may be eligible for a transition drug supply?
- New members during the first 90 days in our plan
- Members residing in a long-term care facility past the first 90 days of membership in our plan
- Members who are negatively affected by a formulary change from one contract year to the next
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). If you need a drug that is not on our formulary or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
For members that move from one level of care to another as described below, Gold Kidney will provide a temporary, one-time up to 30-day supply of a Part D eligible non-formulary medication. This one-time fill needs to be authorized through the exception process. Therefore, your doctor or pharmacist will need to let MedImpact (at 1-888-672-7206) know that you are moving from one level of care to another.
Examples of moving (or transitioning) from one level of care to another include the following:
- Members transitioning from hospital to home (discharge medications)
- Members transitioning from a Skilled Nursing benefit (LTCF) and reverting to the Part D benefit
- Members terminating a Hospice election and reverting to Part A and Part D benefit
- Members discharged from a Chronic Psychiatric Hospital to home (discharge medications)
If you have any questions about our transition policy or need help asking for a formulary exception, call Gold Kidney Customer Service.