Prescription drug transition process
What to do if the member's current prescription drugs are not on the Drug List (formulary) or are restricted in some way.
New members
As a new plan member, they may be currently 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, members should start by talking with their doctor about appropriate alternative medications available on the drug list (formulary). If no appropriate alternatives can be found, the member or their doctor can request a formulary exception. If the exception is approved, the member may be able to obtain the drug for a specified period of time. While the member and their doctor are determining course of action, the member may be eligible to receive a transition supply of at least a 1-month supply as described in the 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 the drug as described in the plan’s Evidence of Coverage. After the transition supply, these drugs may not continue to be covered.
If members live in a long-term care facility but 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 the member asks for a formulary exception.
The member may face unplanned transitions after the first 90 days of plan enrollment, such as hospital discharges or level of care changes (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 the member's ability to get their drug is restricted in some way, they are required to use the plan’s exception process. The member can request a one-time temporary supply of at least a 1-month supply as described in the plan’s Evidence of Coverage (EOC) to allow the member time to discuss alternative treatment with their doctor or to ask for a formulary exception.