As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.
While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply when you go to a network pharmacy. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If 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 a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
We also provide a transition process for members who experience a level-of-care change and are currently on a medication regimen that contains nonformulary drugs or formulary drugs with restrictions. This transition process will occur when the coverage determination processing time frames could interrupt the prescribed drug regimen. We will cover up to a 31-day temporary supply of these non-formulary drugs or formulary drugs with restrictions. Level-of-care changes include discharges from hospitals or psychiatric facilities; admissions to or discharges from long-term care facilities; giving up hospice status; or exceeding the limit for days covered during a skilled nursing facility stay.
If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year.
Please note that our transition policy applies only to Medicare Part D-covered drugs obtained at a network pharmacy. The transition policy cannot be used to buy a non-Part D-covered drug or a drug from an out-of-network pharmacy, unless you qualify for out-of-network access.