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Transition Policy
Know when the plan can offer you a temporary supply of medication:
Temporary Supply of your Medication:
There are some circumstances under which the plan can offer a temporary supply of a drug if the drug is not on the Drug List (Formulary) or if it is subject to certain clinical or utilization management criteria. This gives you time to talk to your doctor about your drug therapy.
If the drug that you have been taking is no longer on your plan’s Drug List or if it now has some prior authorization or step therapy criteria, you can be eligible to obtain a temporary supply.
To be eligible for a transitional or temporary supply of medication, you should be in one of the following situations described below:
For member new to the plan within their first 90 days of enrollment in the plan and your medication is not on the formulary or requires certain utilization management.
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We will cover a temporary supply of your drug during the first 90 days under your plan in the coverage year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.
For those members who were part of the plan last year and aren’t in a long-term care facility.
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We will cover a temporary supply of your drug during the first 90 days under your plan in the coverage year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.
For those who are new members and are residents in a long-term care facility
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If the member is a resident in a long-term care facility, the plan will provide a supply up to 98 days during this period, in accordance with the dispatch increase, with necessary refills (unless the prescription indicates less refills).
Start by talking to your doctor. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor identify a covered drug that might work for you. You can file an exception. You and your doctor or other prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule. For example, you can ask the plan to cover a drug even if it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.
You can file an exception
You and your doctor or other prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule. For example, you can ask the plan to cover a drug even if it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.
For more detailed information, see the "What is an exception?" section of your plan's Evidence of Coverage or call Member Services.