Prescription Drug Transition Process

What to do if your drugs are not on the Drug List (Formulary) or are restricted in some way

Sometimes, you may take a prescription drug that is not on your plan's Drug List, or it is restricted in some way. Whether you are a new member or a continuing member, there is a way to get help.

Start by talking to your doctor. Your doctor can help decide if there is another drug on the Drug List you can switch to. If there is not a good alternative drug, you, your representative, or your doctor can ask for a formulary exception. If the exception is approved, you can keep getting your current drug for a certain period of time.

Review your Evidence of Coverage (EOC) to find out exactly what your plan covers. If you are a continuing member, you will get an Annual Notice of Changes (ANOC). Review the ANOC carefully to find out if your current drugs will be covered the same way in the upcoming year.

Whether you are switching drugs or waiting for an exception approval, you may be eligible for a transition supply of your current drug.

You must get your 1-month supply, as described in EOC, during the first 90 days of membership with the plan as a new member OR within the first 90 days of the calendar year if you are a continuing member and your drug has encountered a negative formulary change.
You may also be eligible for a one-time, temporary 1-month supply if you qualify for an emergency fill while residing in a long-term care (LTC) facility after the first 90 days as a new member or you have encountered a level of care change.
If your doctor writes your prescription for fewer days and the prescription has refills, you may refill the drug until you have received at least a 1-month supply, as described in your EOC.

When am I eligible?

The table below covers when you may be eligible for temporary transition supplies of prescription drugs. Be sure to read your plan's Evidence of Coverage for details.

To read your Evidence of Coverage online, visit the Resources menu and go to Evidence of Coverage. For Medicare Advantage plans, see Chapter 5.

Transition Eligible Situations	Temporary Transition Supply Amount
During the first 90 days of your membership in the plan if you are a new member. During the first 90 days of the calendar year if you were in the plan last year and your drug encountered a negative formulary change.	At least a 1-month supply, as described in your plan's Evidence of Coverage.
For 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.	At least a 31-day supply, as described in your plan's Evidence of Coverage.
Members who have unplanned transitions such as hospital discharges (including psychiatric hospitals) or level of care changes (i.e., changing long-term care facilities, exiting, and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) at any time during the plan year.	At least a 1-month supply, as described in your plan's Evidence of Coverage.

Transition Eligible Situations

Temporary Transition Supply Amount

During the first 90 days of your membership in the plan if you are a new member.

During the first 90 days of the calendar year if you were in the plan last year and your drug encountered a negative formulary change.

At least a 1-month supply, as described in your plan's Evidence of Coverage.

For 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.

At least a 31-day supply, as described in your plan's Evidence of Coverage.

Members who have unplanned transitions such as hospital discharges (including psychiatric hospitals) or level of care changes (i.e., changing long-term care facilities, exiting, and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) at any time during the plan year.

At least a 1-month supply, as described in your plan's Evidence of Coverage.

If you are out of medication after receiving a temporary transition supply and you are working with your prescriber to switch to an alternative drug or request an exception, call the number on your member ID card or contact Customer Service.

How do I ask for a formulary exception?

Your doctor can ask for a formulary exception by using the online tool at https://professionals.optumrx.com. This is recommended for a faster response.
You can call the number on your member ID card or contact Customer Service.
You can download this form and follow the instructions: Medicare Part D Coverage Determination