Drug Transition Policy

Drug Coverage for New Members

Drug Transition Policy

As a new member you may currently be taking drugs that are not on our Drug List, or they are on our drug list but your ability to get them is limited. Under certain circumstances, we can offer a temporary supply of a drug to you when your drug is not on the drug list (formulary) or when it is restricted in some way.

If you are a new member and you do not live in a long-term care facility:

For each of your drugs that is not on the formulary or if your ability to get your drugs is limited we cover an initial 30-day transition supply of the drug anytime during the first 90 days you are a plan member. If the prescription is written for less than 30 days, multiple fills are allowed to provide up to a total of 30 days of the drug.

If you are a new member and are a resident in a long-term care facility:

If you live in a long-term care (LTC) facility and are currently taking a drug that is not on the formulary or your ability to get the drug is limited, we will cover a temporary 31-day transition supply. We will cover more than one refill of these drugs if needed for the first 90 days you are a plan member. If you need a drug that is not on the formulary or your ability to get your drug is limited, but you are past the first 90 days of plan membership, we will cover a one-time emergency supply of up to 31 days to allow you time to discuss alternative treatment with your doctor or to request a formulary exception.

The transition fill will give you time to talk to your doctor and find another medication that will work for you. There may be a similar drug that works just as well, or a generic version of the same drug that has the same active ingredient. If after talking with your doctor, there are no appropriate alternatives on the formulary, you or your can ask us to make an exception and cover that drug. Your doctor will have to give reasons why he/she thinks that you need to take a certain medication.


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H9585_117_092015_Approved
Last Updated 9/30/15