Medicare Part D Transition Process
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. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
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 (LTC) facility, we will allow you to refill your prescription until we have provided you with a 30-day transition supply, consistent with dispensing increment, (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 for fewer days) while you pursue a formulary exception.
You will be sent a transition letter to notify you that you have received a temporary supply of your drug because the drug is not on our formulary, or to notify you that your drug is on the formulary but is subject to restrictions or limits.
If you experience a change in level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility.
If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply.
If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply.
We may make arrangements to continue to provide necessary drugs to you via an extension of the transition period on a case-by case basis.