Prescription drug transition process

What to do if your current prescription drugs are not on the Drug List (formulary) or are restricted in some way.

As a new plan member, you may currently be taking drugs that are not on the plan’s drug list (formulary), or they are on the formulary but are restricted in some way.

In instances like these, start by talking with your doctor about appropriate alternative medications available on the drug list (formulary). If no appropriate alternatives can be found, you, your representative or your doctor can request a formulary exception. If the exception is approved, you may be able to obtain the drug for a specified period of time. While you and your doctor are determining your course of action, you may be eligible to receive a transition supply of at least a 1-month supply as described in your plan’s Evidence of Coverage of most drugs anytime during the first 90 days of membership in the plan.  If the prescription is written for fewer days and has refills, multiple fills are allowed during the first 90 days until you’ve received at least a 1-month supply of your drug as described in your plan’s Evidence of Coverage.  After your transition supply, these drugs may not continue to be covered.

If you live in a long-term care facility but you are past the first 90 days of plan membership, the transition program may cover at least a 31-day emergency supply of most drugs while you ask for a formulary exception.

You may face unplanned transitions after the first 90 days of plan enrollment, such as a hospital discharge (including psychiatric hospitals) or a level of care change (i.e., changing long-term care facilities, exiting and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) that can occur anytime. For many drugs that are not on the drug list (formulary) or your ability to get your drug is restricted in some way, you are required to use the plan’s exception process. You can request a one-time temporary supply of at least a 1-month supply as described in your plan’s Evidence of Coverage (EOC) to allow you time to discuss alternative treatment with your doctor or to ask for a formulary exception.  

As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). You may notice that a drug you are currently taking is either not on the upcoming year’s drug list (formulary) or is on the formulary but restricted in some way.

Starting October 15, 2024, you may request a 2025 coverage review. If your request is approved, the plan will cover the drug as of January 1, 2025.

If your drug is subject to new formulary restrictions on January 1, 2025 and you have not discussed switching to an alternative medication on the drug list (formulary) or asked for a formulary exception with your doctor, you may receive a temporary supply within the first 90 days of the new calendar year when you go to a network pharmacy. This would be at least a 1-month supply as described in your plan’s Evidence of Coverage (EOC) to allow you time to discuss alternative treatment with your doctor or ask us for a formulary exception.  If the prescription is written for fewer days, multiple fills are allowed during the first 90 days until you’ve received at least a 1-month supply of your drug as described in your plan’s Evidence of Coverage.  After your transition supply, these drugs may not continue to be covered.

If you live in a long-term care facility, you can obtain multiple refills until you’ve reached at least a 31-day supply, including when prescriptions are dispensed for less than the written amount due to drug utilization edits that are based on approved product labeling.

There may be unplanned transitions such as a hospital discharge (including psychiatric hospitals) or a level of care change (i.e., changing long-term care facilities, exiting and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) that can occur anytime. If you are prescribed a drug that is not on our drug list (formulary) or your ability to get your drugs is restricted in some way, you are required to use the plan's exception process. For most drugs, you may request a one-time temporary supply of at least one month as described in your plan’s Evidence of Coverage (EOC) to allow you time to discuss alternative treatment with your doctor or to ask for a formulary exception.

If you are a resident of a long-term care facility and need an emergency supply, you may receive at least a 31-day temporary supply.

If you have any questions about this transition policy or need help asking for a formulary exception, a UnitedHealthcare representative can help.

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