What is the Transition Process for new and current members who’s drugs are no longer covered?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited.

You should talk to your doctor to decide if you should:

  • Switch to a drug that we cover; or
  • Request a formulary exception so that we will cover the drug you currently take.

We may cover your drug in certain cases during the first 90 days you are a member of the plan to give you and your doctor time to discuss options.

For each of your drugs that is not on our formulary, or if 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 supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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 if 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 written for fewer days) while you pursue a formulary exception.

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