As a new or continuing member in one of our plans, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage determination) in order to get coverage for the drug . While you and your doctor determine the right course of action, we may cover the non-formulary drug in certain cases during the first 90 days of new membership or for existing members first 90 days of the 2012 plan year.
For each of the drugs that is not on our formulary or that we have coverage restrictions or limits on, we will cover one temporary 30-day supply (unless the prescription is written for fewer days) when you go to a network pharmacy and the drug is otherwise a “Part D drug”. After the 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a new member who is 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), with refills provided, during your first 90 days of membership. If you are past the first 90 days of new membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception or coverage determination.
Other times we will cover a temporary 30-day transition supply (unless the prescription is written for fewer days) are when you enter or leave a long-term care facility, are discharged from a hospital, leave a skilled nursing facility, cancel hospice care, or when you are discharged from a psychiatric hospital on a specialized medication regimen.
