Members

Plan Transition Process

In some circumstances a member’s medications may not be on the Health Choice Generations Formulary. To ensure new Health Choice Generations members receive their medications, Health Choice Generations has created a transition process.

First, you or your provider should check to see if your medication is listed on the Health Choice Generations formulary by either referring to the Health Choice Generations Formulary or by using the on-line searchable formulary.

If your medication is not listed, you should first contact Member Services to be sure it is not covered. If Member Services confirms that we do not cover your drug, you have two options:

  • Receive prior authorization from Health Choice Generations for the drug.
  • Try other drugs on our formulary first, as part of a step therapy program.

In some cases, a drug that is being requested is on our formulary; but safety limits do not allow us to provide the full amount that was prescribed.

We strongly encourage members to call their doctor. They may switch you to another drug that is covered on our formulary, or you or your physician may request a formulary exception.

How do I change my prescription?

You can ask us if we cover other drugs used to treat your medical condition. If we cover another drug for your condition, you can ask your doctor if any of these drugs may be an option for you. If your doctor tells you that none of the drugs we cover for treatment of your condition is medically appropriate, you have the right to request a formulary exception from us. You also have the right to ask for a change in the quantity limit we have placed on a drug you are taking for treating your condition.

How do I request an exception?

The first step in requesting an exception is for you or your prescribing doctor to contact us by mail, fax or by phone at one of the following:

Attn: Pharmacy Department
410 N. 44th Street, Ste. 900
Phoenix, AZ 85008
Phone: 1-800-656-8991

Fax: 1-888-291-4542

Your doctor must submit a statement supporting your request. The doctor?s statement must indicate that the requested drug is medically necessary for treating your condition because none of the drugs on the formulary would be as effective, or would cause adverse effects. If the exception involves a prior authorization, quantity limit, or other limit we have placed on a drug you are taking, the doctor?s statement must indicate that the prior authorization or limit would not be as effective for treating your condition or would cause adverse effects.

Once the physician’s statement is submitted, we must notify you of our decision no later than 24 or 72 hours, depending on whether the request is an expedited request or a standard request. Your request will be expedited if we determine, or your doctor tells us, that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.

What if my request is denied?

If your request is denied, you have the right to appeal by asking us to review our decision. You must request this appeal within 60 calendar days from the date of our first decision. We accept standard and expedited requests by telephone and in writing (by mail or fax). We recommend the use of fax or telephone for expedited requests so we can address your request as quickly as possible.

Attn: Pharmacy Department
410 N. 44th Street, Ste. 900
Phoenix, AZ 85008

Phone: 1-800-656-8991
Fax: 1-888-291-4542

If you need help in asking for a formulary exception or for more information about our transition policy, please call Member Services at 1-800-656-8661. TTY/TDD users should call 711. We are available from 8 am – 8 pm, 7 days a week.

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