Transition of Care
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Establishes Peach State Health Plan's process to provide continuity of prescription drug therapy for new members transitioning from another insurer, including a one-time 30-calendar-day coverage for medications that would otherwise require prior authorization. Applies to the Peach State Health Plan Pharmacy Department and Medicaid product members.
No material clinical or coverage changes in this revision.
Transition Coverage Criteria
Transition fill coverage and procedures
Coverage and process for new members' medications that were previously covered by another insurer:
One-time Continuation of Therapy
One-time 30-day continuation
Temporary continuation of previously authorized medications when a member becomes new to Peach State Health Plan:
Provider Responsibilities and Actions
Provide one-time 30-calendar-day transition fill and initiate PA review
Medications that were covered by the member's prior insurer and would require prior authorization under Peach State Health Plan are eligible for a one-time 30-calendar-day transition fill to allow time for prior authorization review. Provide the temporary 30-day supply from the member's new effective date and submit any prior authorization request during that period if continued therapy is needed.
- One-time 30-calendar-day transition fill provided for medications not on the preferred drug list or with limits/restrictions.
- Centene Pharmacy Services will send a daily Transition of Fill (TOF) report to identify affected new members.
- Pharmacy staff will review TOF report, identify chronic/maintenance medications, and mail notification letters to member and prescriber.
Definitions
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