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New members in our Plan may be taking drugs that aren't on our
formulary or that are subject to certain restrictions, such as prior
authorization or step therapy. Current members may also be affected by
changes in our formulary from one year to the next. Members should talk
to their doctors to decide if they should switch to a different drug
that we cover or request a formulary exception in order to get coverage
for the drug. See chapter 9 of the Evidence of Coverage under
"What is an exception?" to learn more about how to request an
exception.
Please contact Member Services if your drug is not on our formulary,
is subject to certain restrictions, such as prior authorization or step
therapy, or will no longer be on our formulary next year and you need
help switching to a different drug that we cover or requesting a
formulary exception.
During the period of time members are talking to their doctors to
determine the right course of action, we may provide a temporary supply
of the non-formulary drug if those members need a refill for the drug
during the first 90 days of new membership in our Plan. If you are a
current member affected by a formulary change from one year to the
next, we will provide a temporary supply of the non-formulary drug if
you need a refill for the drug during the first 90 days of the new plan
year OR provide you with the opportunity to request a formulary
exception in advance for the following year.
When a member goes to a network pharmacy and we provide a temporary
supply of a drug that isn't on our formulary, or that has coverage
restrictions or limits (but is otherwise considered a "Part D
drug"), we will cover a 30-day supply (unless the prescription is
written for fewer days). 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 with a written notice after we cover your
temporary supply. This notice will explain the steps you can take to
request an exception and how to work with your doctor to decide if you
should switch to an appropriate drug that we cover.
If a new member is a resident of a long-term-care facility (like a
nursing home), we will cover a temporary 31-day transition supply
(unless the prescription is written for fewer days). If necessary, we
will cover more than one refill of these drugs during the first 90 days
a new member is enrolled in our Plan. If the resident has been enrolled
in our Plan for more than 90 days and needs a drug that isn't on our
formulary or is subject to other restrictions, such as step therapy or
dosage limits, we will cover a temporary 31-day emergency supply of
that drug (unless the prescription is for fewer days) while the new
member pursues a formulary exception.
Please note that our transition policy applies only to those drugs
that are "Part D drugs" and bought at a network pharmacy. The
transition policy can't be used to buy a non-Part D drug or a drug out
of network, unless you qualify for out of network access. See Chapter 6
of the Evidence of Coverage for information about non-Part D drugs.
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