ODS. Healthcare from your head to your toes.

Transition Policy

For each of the drugs that aren’t on our formulary or that have coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is a Part D-eligible drug). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you and your provider with a written notice after we cover your temporary supply, explaining the steps you can take to satisfy the coverage restrictions or limits on the drugs you take.

If your drug is not on the Drug List or is restricted, here are things you can do:

You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file an exception.
You can change to another drug.
You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply

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 (step therapy, prior authorization or quantity limit rules).

2. You must be in one of the situations described below:

For those members who were in the plan last year and aren’t in a long-term care facility:

We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

For those members who are new to the plan and aren’t in a long-term care facility:
We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
For those who are a new member and a resident in a long-term care facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
For those who have been a member of the plan for more than 90 days and are a resident of a long-term care facility and need a supply right away:
We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
For those who have been a member of the plan for more than 90 days and experience a level of care change and need a supply right away:
We will cover one 31-day supply, or less if your prescription is written for fewer days.

To ask for an additional temporary supply, call customer service.

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. Perhaps there is a different drug covered by the plan that might work just as well for you. You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. The sections below tell you more about these options.

You can change to another drug

Start by talking with your provider. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call customer service to ask for a list of covered drugs that treat the same medical condition. This list can help your provider to find a covered drug that might work for you.

You can file an exception

You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan’s drug list. You can ask the plan to make an exception and cover the drug without restrictions.
If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for the following year. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for the following year. We will give you an answer to your request for an exception before the change takes effect.