What if my current prescription drugs are not on the formulary or are limited on the formulary?

New Members

As a new member in our plan, 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 available 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 you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30-day transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day transition supply we may not continue to pay for these drugs under the transition policy.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 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, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Continuing Members

 As a continuing member in the plan, you will receive your Annual Notice Of Change (ANOC) by October 31st. You may notice that a formulary medication which you are currently taking is either not on the upcoming year’s formulary or its cost sharing or coverage is limited in the upcoming year. In this case, you must work with your doctor to either find an appropriate alternative on our new formulary or request a formulary exception prior to the beginning of the new year. If the exception request is approved, we will authorize payment prior to January 1st and provide coverage beginning January 1st.

Enrollees who remain in the same plan they were enrolled in for 2007 and are on a drug that has a PA requirement that is expiring – prior to the beginning of the new plan year may either attempt to satisfy the PA requirement by requesting a coverage determination, or by requesting a formulary exception if he/she can not satisfy the PA requirement.

Current Enrollees with Level of Care Changes

 If a current enrollee experiences a level of care change causing the script to initially reject at the pharmacy, the pharmacist will call the pharmacy help desk, explain the level of care change, and request an override to allow the claim to process. For example, enrollees experiencing a change in treatment settings outside of any other valid transition period would receive a 14-day transition supply for a non-formulary drug, a formulary PA drug, or step therapy drug. If such a change in treatment settings occurs during another valid transition period (for example during the first 90 days of enrollment in the plan), then the longer transition rule will be applied.

Current enrollees entering LTC from other care settings will be supplied emergency supplies of non-formulary drugs, including Part D drugs that are on a plan’s formulary but require prior authorization or step therapy under a plan’s utilization rules. This transition supply is not limited only to initial enrollment.

If you have any questions about our transition policy or need help asking for a formulary exception, call customer services at 1-888-369-7979 / 1-888-369-7373. TTY/TDD users should call 1-866-369-7373.