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Prescription Transition

Our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Chapter 6 of the Evidence of Coverage for information about non-Part D drugs.

 

New Members

If you are a new member in our Plan you may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. If you are a current member you may also be affected by changes in our formulary from one year to the next. You should talk to your doctor to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Chapter 9 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception.

Please contact our Member Navigation Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.

During the period of time you are talking to your doctor to determine the right course of action, we may provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year.

When you go to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If you are resident of a facility (like a nursing home), we will cover a temporary transition supply up to 98 days, consistent with the dispensing increment, with refills provided, if needed, unless the prescription is for fewer days. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the you've been enrolled in our Plan for more than 90 days and need a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the member pursues a formulary exception.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to cover a non-Part D drug or a drug supplied out of network, unless you qualify for out of network access. See Chapter 6 of the Evidence of Coverage for information about non-Part D drugs.

 

Current Members

You may be affected by changes in our formulary from one year to the next. You should talk to your doctor to decide if you should switch to a different drug that we cover, or request a formulary exception in order to get coverage for the drug. See Chapter 9 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact Member Navigation Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover, or to request a formulary exception.

If you are affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year, or provide you with the opportunity to request a formulary exception in advance for the following year.

When you go to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

 

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10/03/2012
H3818_WEB_00248v2 CMS Approved