Plan transition policy for prescription drugs
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the 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:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan’s Drug List.
- -- or -- the drug you have been taking is now restricted in some way.
- You must be in one of the situations described below:
- For those members who were in the plan last year and aren’t in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
- For those members who are new to the plan and aren’t in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
- For those members who are new to the plan and reside in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a one month supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a one month supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
- We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
- If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a one-time temporary supply for up to 30 days (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. During this period, you can discuss alternative treatments with your doctor or use the plan’s exception process if you wish to continue coverage of the drug after the temporary supply is finished. Our transition policy will not cover drugs that Medicare does not normally cover.
- For those members who were in the plan last year and aren’t in a long-term care (LTC) facility:
To ask for a temporary supply, call the Medicare Concierge team.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.