Leon Health wants to be sure that you, as a new or existing member, safely transition into the 2025 plan year. Therefore, LH will cover your drug during the first 90 days if you are a member of our plan regardless of the drug not being on our drug list, whether the drug requires prior authorization, has a step therapy requirement, or has a quantity limit. If your prescription is written for fewer days, we will allow refills to provide up to a maximum one-month supply of medication.
After you receive your transition supply, we will send you a letter. The letter will:
- Explain the temporary nature of the transition medication supply,
- Instruct you on how to work with your prescriber to satisfy any prior authorization, step therapy, quantity limit requirements, or to identify appropriate drug alternatives that are on our drug list,
- Explain your right to request a formulary exception; and a description of the procedures for requesting a formulary exception.
You should make sure that you talk to your prescriber during this transition period to decide what to do before your supply runs out.
Transition Fills for New Members in the Long-Term Care (LTC) Setting
LH will ensure that if you are in a long-term care (LTC) setting, you’ll get a one-time temporary fill of at least a month’s supply during the first 90 days of your enrollment in the plan.
Our transition policy provides for a 31-day emergency supply (unless you present a prescription written for less than 31 days), in which case we will allow multiple fills to provide up to a total of 31 days. The 31-day supply includes non-formulary Part D drugs or a drug subject to other restrictions. In addition, the transition fill will allow you or your prescriber time to request an exception, step therapy, or prior authorization for the medication you need. This policy applies if you are admitted to or discharged from an LTC facility.
Current members that need a one-time emergency fill or that are prescribed a non-formulary drug as a result of a level of care change can be placed in transition and receive a one-time fill of a non-formulary drug or a drug subject to other restrictions.
LH will ensure that cost-sharing for a temporary supply of drugs provided under our transition process does not exceed the maximum co-payment amounts if you are a low-income subsidy (LIS) eligible member. However, if you do not have a low-income subsidy (LIS), you will be charged the same cost-sharing amount that you would pay when we approve a formulary exception or a formulary drug that is subject to utilization management edits.
LH will ensure that this policy addresses procedures for medical review of non-formulary drug requests, and when appropriate, a process for switching new Part D plan members to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and dispensed at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network unless the drug claim qualifies for out-of-network reimbursement.
For more information about your Leon Health prescription drug coverage, please review your Evidence of Coverage (EOC). If you have questions about Leon Health, please call our Member Services Department at the toll-free Number (844) 969-5366, or local at: (305) 541-5366. (TTY users should call 711). Hours of operation are from 8 a.m. to 8 p.m. EST, seven days a week from October 1st through March 31st and Monday through Friday the rest of the year.
