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Drug Transition Policy

If a drug you are taking is not on the List of Drugs (Formulary) or is restricted in some way, here are things you can do:

  • You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your doctor or other prescriber time to change to another drug or to file a request to have the drug covered.
  • You can change to another drug.
  • You can request an exception and ask us to cover the drug or remove restrictions from the drug.

To be eligible for a temporary supply, you must meet BOTH of the two rules below:

1.     The drug that you take:

  • Is no longer on our list of drugs OR
  • Was never on our list of drugs OR
  • Is now limited in some way

(Chapter 5 in the Member Handbook has more information.)

AND

2.     You are in one of these situations:

For Medicare Part D drugs:

    You were in the plan last year.

  • We will cover a temporary supply of your drug during the first 90 days of the calendar year.
  • This temporary supply will be for up to 30 days of medication at a retail pharmacy and at a long-term care pharmacy, up to 31 days.
  • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication at a retail pharmacy and at a long-term care pharmacy, up to 31 days of medication. You must fill the prescription at a network pharmacy.
  • Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.

    You are new to the plan.

  • We will cover a temporary supply of your drug during the first 180 days of your membership in the plan.
  • This temporary supply will be for up to 30 days of medication at a retail pharmacy and at a long-term care pharmacy, up to 31 days.
  • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication at a retail pharmacy and at a long-term care pharmacy, up to 31 days of medication. You must fill the prescription at a network pharmacy.
  • Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.

    You have been in the plan for more than 90 days and live in 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 temporary supply.

Throughout the plan year, you may have a change in your treatment setting (a place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to:

  • Members who are discharged from a hospital or skilled nursing facility to a home setting.
  • Members who are admitted to a skilled nursing facility from a home setting.
  • Members who transfer from one skilled nursing facility to another and are served by a different pharmacy.
  • Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit.
  • Members who give up hospice status and go back to standard Medicare Part A and B coverage.
  • Members discharged from chronic psychiatric hospitals with highly individualized drug regimens.
  • For these changes in treatment settings, we will cover as much as a 30-31-day temporary supply of a Part D-covered drug when you fill your prescription at a pharmacy. If you change treatment settings multiple times within the same month, your pharmacy may need to contact the plan for continued coverage. If you do not request continued coverage from the plan, you do not qualify for an additional level of care transition fill, unless it is a life-threatening emergency.
  • To ask for a temporary supply of a drug, contact Member Services.

For Medicaid drugs:

    You are new to the plan.

  • We will cover a supply of your Medicaid drug for up to 90 calendar days after enrollment, and will not terminate it at the end of the 180 calendar days without advance notice to you and a transition to another drug, if needed. 
  • To ask for a temporary supply of a drug, contact Member Services.

For low-income subsidy (LIS)-eligible enrollees, the cost-sharing for a temporary supply will never exceed the maximum copayment amount.

After you get your temporary supply

Within three business days after you receive your temporary supply, you and your doctor will receive a letter explaining what to do next. You should talk with your doctor to decide what to do when your supply runs out. You can:

  • Change to another drug. We could have other drugs that might work for you. You can contact Member Services to ask for a list of covered drugs. Share it with your doctor to decide if there is an alternate drug that would be just as effective for your condition.
  • Ask for an exception. You or your doctor can ask us to make an exception or submit a request for coverage determination. For example, you can ask us to cover a drug even though it is not on our list of drugs. Or you can ask us to cover the drug without limits. 

 

If you have any questions, call Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.