Drug Transition Plan
What can you do if your drug is not on the Formulary (drug list) or if the drug is restricted in some way?
If your drug is not on the Formulary or is restricted, 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 provider 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 the plan to cover the drug or remove restrictions from the drug.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan’s Formulary
- -- OR -- the drug you have been taking is now restricted in some way
- You must be in one of the situations described below:
- For those members who were in the plan last year and aren’t in a long-term care (LTC ) facility:
We will cover a temporary supply of your 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. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
For those members who are new to the plan and aren’t in a long-term care (LTC) 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. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
For those members who were in the plan last year and reside in a long-term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of the calendar year. The total supply will be for a maximum of 31 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
For those members who are new to the plan and reside in a long-term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The total supply will be for a maximum of 31 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) 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.
For those members who have been in the plan for more than 90 days and experience a level of care change (from one treatment setting to another):
We will provide up to a 31-day supply of a non-Formulary drug, or less if your prescription is written for fewer days.