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Medicare.gov Resources

Medicare.gov Medicare Complaint Form Medicare Prescription Drug Coverage Determinations Best Available Evidence for Low-Income Subsidy

Transition Policy

Sometimes you may take a prescription drug that is not on our plan’s formulary or a drug that has certain limitations, such as prior authorization or step therapy. Whether you are a new member or an existing member, you may be able to get a temporary, limited supply of your drug (transition fill).

You should start by talking with your doctor about the non-formulary drug and possible alternative drugs that are on the plan’s formulary. It’s a good idea to take your formulary with you when you visit your doctor.

 

For New Members

If you are new to our plan, you may be taking a drug that is not on our formulary or has certain limitations. During the first 90 days of your coverage in our plan, your pharmacy will be able to fill a temporary, 30-day supply (transition fill) of your non-formulary drug. A transition fill allows you time to discuss formulary alternatives with your doctor or other prescriber.

If your doctor or other prescriber determines there is not a safe and/or effective alternative drug on our formulary, you or your doctor may ask us for a Formulary Exception. If your request for a Formulary Exception is approved, you will be able to obtain the non-formulary drug for a specified period of time.

 

Existing Members

The plan’s formulary may change at the beginning of a new year. A drug that you take may be taken off the formulary or the drug may be subject to new limitations. It’s important that you review the formulary before the beginning of the new plan year to confirm that your prescription drugs will continue to be on the formulary.

During the first 90 days of the calendar year, your pharmacy will be able to fill a temporary, 30-day supply of your drug. If your doctor or other prescriber determines there is not a safe and/or effective alternative drug that is on our formulary, you or your prescriber may ask us for a Formulary Exception. If your request for a Formulary Exception is approved, you will be able to obtain the non-formulary drug for a specified period of time.

For members who have been on the plan for more than 90 days and reside in a long term care facility, up to a 31-day emergency supply may be available to while the formulary exception or prior authorization is being reviewed.

If you experience a level of care change, the plan may provide up to a 31-day supply of your drug while the formulary exception or prior authorization is being reviewed. A level of care change includes being discharged from the hospital to a home setting or long-term care setting.