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.
Talk to Your Doctor
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. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. 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.
For Long-term Care Facility Residents
If you're a resident of a long-term care facility, we'll allow you to refill a prescription until we have provided you with at least a 31-day supply. We'll cover more than one refill of these drugs for the first 90-days you're a member of our plan.
If you are a resident of a long-term care facility and 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 while you pursue a formulary exception.
Level of Care Changes
If you change your level of care, such as a move from a hospital to a home setting, and 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 up to a temporary 30-day supply (or 31-day supply if our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30- day supply, you are required to use the plan’s exception process. Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover or drugs that might be covered under Medicare Part B.