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 can change to another drug that is on the List of Drugs (Formulary).
To ask for a temporary supply of a drug, contact Member Services.
Change to another drug. We could have other drugs on the List of Drugs (Formulary) that might work for you. You can contact Member Services to ask for this list. Share it with your doctor to decide if there is an effective alternate drug.
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.
In certain situations and following CMS requirements, we can offer you a temporary supply of your drug. A temporary supply helps your immediate need. It also gives you time to talk with your doctor about a different dose or another drug that we do cover, or to complete an exception request.
(Chapter 5 in the Evidence of Coverage has more information).
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply at retail pharmacy, or a 31-day supply at a long term care pharmacy. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply of medication at a retail pharmacy, and a 31-day supply of medication at a long-term care pharmacy. The prescription must be filled at a network pharmacy. (Please note, the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
We will cover a temporary supply of your drug during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply at a retail pharmacy, or a 31-day supply at a long term care pharmacy. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply of medication at a retail pharmacy, and a 31-day supply of medication at a long-term care pharmacy. The prescription must be filled at a network pharmacy. (Please note, the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)