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Drug Transition Policy

If a drug that you take is not on our List of Drugs (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 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.

In certain situations and following Centers for Medicare & Medicard Services (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.

To be eligible for a temporary supply, you must meet BOTH of the two requirements 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 restricted in some way

       (Chapter 5 in the Evidence of Coverage (EOC) has more information).

AND

2.    You are in one of these situations:

You are new to the plan:

  • 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.)

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 if you were in the plan last year. 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.)

You have been a member for more than 90 days, you are in a long-term care facility, and you 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 supply. When your prescription is filled you and your doctor should request an exception or prior authorization.

Additionally, based on your required level of care, the place where you get and take your drugs (your treatment setting) could change. This could be, but is not limited to, if you:

  • Are discharged from a hospital or a skilled nursing facility to a home setting, or
  • Are admitted to a hospital or a skilled nursing facility from a home setting, or
  • End your skilled nursing facility (Medicare Part A) stay, where payments include all pharmacy charges, and you need to use your Part D plan benefit, or
  • Give up hospice status and go back to standard Medicare Part A and B coverage, or
  • Are discharged from a psychiatric hospital with a highly individualized drug regimen.

For these treatment setting changes, we will cover as much as a 30-31-day temporary supply of a Part D-covered drug when filled at a network pharmacy.

If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization for continued coverage of your drug. We review continuation of therapy requests on a case-by-case basis if you are on a stabilized drug regimen that, if changed, is known to have risks.

There are other situations where you may receive a temporary supply. To ask for a temporary supply of a drug, contact Member Services.

For low-income subsidy (LIS)-eligible members, 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 may have other drugs that might work for you. You can contact Member Services to ask for a List of Covered Drugs (Formulary). Share the list 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 (Formulary). Or, you can ask us to cover the drug without limits.