Transition Process

What if my current prescription drugs are not on the formulary or are limited on the formulary?

New Members

As a new member in our plan, you currently may be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30-day transition supply of the drug anytime during the first 90 days that you are a member of our plan.

For each of your drugs that is not on our formulary, or for situations in which 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 transition supply, we may not continue to pay for these drugs under the transition policy.

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 that you are a member of our plan. If you need a drug that is not on our formulary, or your ability to get your drug 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.

Continuing Members

As a continuing member in the plan, you will receive your Annual Notice of Change (ANOC) by October 31st. You may notice that a formulary medication that you currently are taking is either not on the upcoming year's formulary or its cost sharing or coverage is limited in the upcoming year.

In this case, you must work with your doctor to either find an appropriate alternative therapy on our new formulary or request a formulary exception before the beginning of the new year. If the exception request is approved, we will authorize payment before January 1st and provide coverage beginning January 1st.

If you experience a level of care change that causes a prescription to reject (i.e., a change in treatment setting such as a discharge from the hospital), you will receive a temporary transition supply for either a non-formulary drug or a formulary prior authorization drug.

If you have any questions about our transition policy or need help asking for a formulary exception, call Member Services at one of the telephone numbers on this page.