Medication Transition Process 2023
New members in our health plan may be taking drugs that aren't on our formulary (list of drugs) or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See your Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.
During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our plan. Under certain circumstances, our plan can offer a temporary supply of a drug to a member when their drug is not on the Drug List or when it is restricted in some way. Doing this gives the member time to talk with their doctor about the change in coverage and figure out what to do.
To be eligible for a temporary supply, the member must meet the two requirements below:
- The change to a member's drug coverage must be one of the following types of changes:
- The drug the member has been taking is no longer on the plan's Drug List OR
- The drug the member has been taking is now restricted in some way.
- The member must be in one of the situations described below:
- For those members who were in the plan last year and are not in a long-term care facility: We will cover a temporary supply of drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
- For those members who are new to the plan and are not in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
- For those who are a new member and a resident in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days.
- For those who have been a member of the plan for more than 90 days and are a resident of a long-term care facility and need a supply right away: We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
- If a member changes their level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan's exception process. Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover, such as drugs that might be covered under Medicare Part B.
During the time when a member is getting a temporary supply of a drug, they should talk with their doctor to decide what to do when their temporary supply runs out. There may be a different drug covered by the plan that might work just as well for them. Or the member and their doctor can ask the plan to make an exception and cover the drug in the way they would like it to be covered.
Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought 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 you qualify for out-of-network access.
For more information regarding our Transition Process please call our Medicare Prescription Drug Program at 1-888-296-6961, 24 hours a day, 7 days a week. Or you can get a copy of our Transition Policy here.