Transition Process - 2010

How to change to a medicine on our formulary

If your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year, and you need help switching to an appropriate drug that we cover or requesting a formulary exception, please contact Member Services.

Members should talk to their doctors to decide if they should:

• Switch to an appropriate drug that we cover, or 
• Request a formulary exception (which is a type of coverage determination) in order to get coverage for the drug

During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our plan.

If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year. We will also provide you with the opportunity to request a formulary exception in advance for the following year. For each of the drugs that isn't on our formulary or that has coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is otherwise a "Part D drug"). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90-days a new member is enrolled in our plan, when that member is a resident of a long-term care facility. If a new member, who is a resident of a long-term care facility and has been enrolled in our Plan for more than 93 days, needs a drug that isn't on our formulary or subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

If a current member leaves or enters a facility such as a hospital, and the member receives a prescription for a drug that is not on our formulary or that is subject to certain restrictions, such a prior authorization or step therapy, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and that are bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.

Long Term Care Out of Network Policy

Plan drugs may be covered in special circumstances, for instance, illness while travelling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drugs and submit documentation to receive reimbursement from Passport Advantage (HMO). You can get a 10-day supply of drugs.