General Transition Notice
What if my current prescription drugs are not on the formulary or are limited on the formulary?
New Members
As a new member, you may currently be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies that are on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While your course of action is being determined, you may be eligible to receive an initial 30 days transition supply (or less if your prescription is written for fewer days) of the drug anytime during the first ninety (90) days of your membership.
For each of your drugs that is not on our formulary or for situations where the ability to get your drugs is limited, we will cover a temporary 30-day supply (or less if your prescription is written for fewer days) as long as you use a network pharmacy. After your first 30-day transition supply, we may not continue to pay for your drugs under the transition policy. You should discuss alternative therapies on our formulary with your doctor and if there are none, you or your doctor can request a formulary exception.
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (or less if your prescription written for fewer days). We will cover more than one refill of these drugs for the first ninety (90) days you are a member of our plan. If you need a drug that is not on our formulary or your ability to get your drugs is limited and you are past the first ninety (90) days of membership in our plan, we will cover a 31-day emergency supply of that drug (or less if your prescription is written for fewer days) while you pursue a formulary exception.
Continuing Members
As a continuing member, you will receive your Annual Notice Of Change (ANOC) by October 31st. You may notice that a formulary medication that you are currently taking is either not on the upcoming year’s formulary or its cost sharing or coverage is limited. If this is the case, we will provide for a transition period consistent with the above stated transition process for new enrollees. The only exception to this process is for erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra and Caverject. Under new Medicare regulations, most ED drugs will no longer be covered.
Current Members with a change in their level of care
Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows:
§ Beneficiaries who are discharged from the hospital and are provided a discharge list of medications based upon the formulary of the hospital
§ Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payment includes all pharmacy charges) and who need to revert back to their Part D plan formulary
§ Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits
§ Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized
All of these situations would warrant a temporary one-time fill exception even if the beneficiary is outside of their first ninety (90) days of program enrollment. If you have any questions about our transition policy or need help asking for a formulary exception, call Customer Services at 1-800-546-5677, 24 hours a day, 7 days a week, TTY/TDD users should call 1-866-706-4757.
