Drug Transition Policy

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

  1. The change to your drug coverage must be one of the following types of changes:
    • The drug you have been taking is no longer on the plan’s Drug List.
    • Or — the drug you have been taking is now restricted in some way (Chapter 5, Section 4 of the EOC talks about restrictions).
  2. You must be in one of the situations described below:
    • For those members who are new or who were in the plan last year and are not in a long-term care (LTC ) facility:
      • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
    • For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
      • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
      • For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away: we will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

Click here to view our Transition Policy.

Y0027_18-330 - Last updated 12/20/2018