Medication Transition Policy

We try to make your drug coverage work well for you, but sometimes a drug might not be covered in the way that you would like it to be. For example:

  • The drug you want to take is not covered by the plan. The drug is not on the drug list. A generic version of the drug is covered, but the brand name version you want to take is not. A drug is new and we have not yet reviewed it for safety and effectiveness.
  • The drug is covered, but there are special rules or limits on coverage for that drug. Some of the drugs covered by the plan have rules that limit their use. In some cases, you or your prescriber may want to ask us for an exception to a rule.

There are things you can do if your drug is not covered in the way that you would like it to be.

  • You can get a temporary supply
    In some cases, the plan can give you a temporary supply of a drug when the drug is not on the drug list or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask the plan to cover the drug.
    To get a temporary supply of a drug, you must meet the two requirements below:
    1. The drug you have been taking:
    • Is no longer on the plan's drug list.
    • Was never on the plan's drug list.
    • Is now limited in some way.

2. You must be in one of these situations:

  • You were in the plan last year and do not live 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 30-day supply for Part D drugs and a 90-day supply for non-Part D drugs. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medicine for Part D drugs and 90 days of medicine for non-Part D drugs. You must fill the prescription at a network pharmacy.
  • You are new to the plan and do not live in an LTC facility.
    We will cover a temporary supply of your drug during the first 180 days of your membership in the plan. This temporary supply will be for a 30-day supply for Part D drugs and a 90-day supply for non-Part D drugs. You must fill the prescription at an in-network pharmacy.
  • You are new to the plan and live in an LTC facility.
    We will cover a temporary supply of your drug during the first 180 days of your membership in the plan. The total supply will be for up to a 31-day supply for Part D drugs and a 31-day supply for non-Part D drugs. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of the number of days allowed. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
  • You have been in the plan for more than 90 days and live in an 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 LTC transition supply.

Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who:

  • Enter LTC facilities from hospitals, who are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short-term planning taken into account (often under eight hours).
  • Are discharged from a hospital to home.
  • End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
  • End an LTC facility stay and return to the community.

If a member has more than one change in level of care in a month, the pharmacy must call our plan to request an extension of the transition policy.

To ask for a temporary supply of a drug, call Member Services.

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:
1. You can change to another drug.
There may be a different drug covered by the plan that works for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.

2. You can ask for an exception.
You and your provider can ask the plan to make an exception. For example, you can ask the plan to cover a drug even though it is not on the drug list. Or you can ask the plan to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

If you need help asking for an exception, you can contact Member Services or your care coordinator.

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Members 2025