General Transition Notice
Under certain circumstances, we will cover a temporary supply of a medication for you when your medication is not on the Formulary (Drug List) or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your medication coverage must be one of the following types of changes:
- The medication you have been taking is no longer on the plan's Formulary (Drug List). -OR-
- The medication you have been taking is on the Formulary (Drug List), but is limited in some way.
2. You must be in one of the situations described below:
You were in the plan last year. You aren't in a long-term care facility:
We will cover a temporary supply of your medication one time only during the first 90 days of the membership in the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
You're new to the plan. You aren't in a long-term care facility.
We will cover a temporary supply of your medication one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
You're new to the plan. You’re in a long-term care facility.
We will cover a temporary supply of your medication during the first 90 days of your membership in the plan. This temporary supply may be up to 31 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
You've been in a long-term care facility for more than 90 days and need a supply right away.
We will provide an emergency supply of non-formulary, formulary medications that require a prior authorization or step therapy must be for at least 31 days, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
Your level of care has changed.
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 one-time temporary fill exceptions when they are outside of the three-month effective date into the Part D program are as follows:
- If a beneficiary was discharged from the hospital and was 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 payments include 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 regardless of whether or not the beneficiary is in the first 90 days of program enrollment.
Please note that our transition policy applies only to those medications that are "Part D medications" and purchase at a network pharmacy. The transition policy can't be used to acquire a non-Part D medication or a medication out of network, unless you qualify for out-of-network access.
During the time when you are getting a temporary supply of a medication, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different medication covered by the plan or ask the plan to make an exception for you and cover your current medication. If you have any questions about our transition policy or need help requesting a formulary exception, call Member Services at 1-800-499-2793, between 8:00 a.m. - 8:00 p.m., 7 days a week from October 1 to February 14, and 8:00 a.m. - 8:00 p.m., Monday to Friday from February 15 to September 30, TTY/TDD users should call 711.