EFFECTIVE JANUARY 1, 2019
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:
- 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.
- You must be in one of the situations described below:
- For those members who are new or who were in the plan last year:
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 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.
- For current members with a change in their level of care:
- Current enrollees transitioning to an in-network long-term care facility with a new prescription for a drug that is not on our formulary, or a drug that is subject to prior authorization, step therapy or quantity limit requirements, will receive a temporary 31-day supply (unless the prescription is written for fewer days) from the network pharmacy.
- Medication transition supplies that are subject to point-of-sale quantity limit edits allowing for less than the prescribed quantity can be refilled up to the prescribed amount for a 31-day supply (long-term care facility residents) within the first 90 days while an exception is requested and processed.
- If you enroll after we distribute the Annual Notice of Changes (ANOC) and have a level of care change prior to the new plan year, you will be provided a transition supply consistent with the transition process used for other enrollees with level of care changes. Our transition process is updated annually, or as needed.
To ask for a temporary supply, call Customer Care at (844) 280-5555 (TTY users call 711).
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.