Transition Supply Policy
Under certain circumstances, we will provide a temporary supply of a Part D covered drug that is not on our Drug List (formulary) or has restrictions, such as needing a prior authorization. This temporary supply, called a transition fill, gives you time to talk with your provider about the change in coverage and decide what to do. This could occur during the first 90 days you are a member of our plan (for new members), or, in certain cases for continuing members affected by a negative formulary change across plan years, during the first 90 days of the new plan contract year.
New Members: For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover one temporary one-month (30-day) supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
Continuing Members: During the first 90 days of the new plan contract year, for each of your drugs that has affected by a negative formulary change, such as being removed from our Drug List, we will cover one temporary one-month (30-day) supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will no longer pay for these drugs.
Long-Term Care Resident: If you’re a resident of a long-term care facility, we’ll allow you to refill a prescription until we have provided you with at least a 31-day supply.
All members (and their prescribing provider) who has received a transition fill, will be sent a letter explaining the reason for the transition fill and information about the process. This letter will be sent within three business days of the transition fill.
For members who have been enrolled in our plan for more than 90 days and reside in a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover one 31-day emergency supply of that drug while you pursue a prior authorization or formulary exception.
If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. During this period, you can discuss options with your provider or use the plan’s exception process if you wish to continue coverage of the drug after the temporary supply is finished.
Our transition policy will not cover drugs that Medicare Part D does not normally cover.
For More Information
For more detailed information about your eternalHeath prescription drug coverage, please review your Evidence of Coverage.
If you have questions about our transition policy or need help asking for a formulary exception, please contact Pharmacy Member Services at 1 (800) 891-6989, 24 hours a day, 7 days a week. TTY users call 711.
