Medicare Advantage Plans

Prescription Drug Transition Process

What to do if your current prescription drugs are not on the formulary or are limited on the formulary.

 

New members

As a new member of a UnitedHealthcare® Medicare Advantage plan, you may currently be taking drugs that are not on the UnitedHealthcare formulary (drug list), or they are on the formulary but your ability to get them is limited.

In instances like these, start by talking with your doctor about appropriate alternative medications available on the formulary. If no appropriate alternatives can be found, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug for a specified period of time. While you and your doctor are determining your course of action, you may be eligible to receive an initial 31-day transition supply (unless your prescription is written for less than 31 days) of the drug anytime during the first 90 days you are a plan member.

For each of your drugs that is not on the formulary or if your ability to get your drugs is limited, UnitedHealthcare will cover a 31-day supply (unless your prescription is for less than 31 days) when you go to a network pharmacy. If the prescription is written for less than 31 days, multiple fills are allowed to provide up to a total of 31 days of drugs. After your first 31-day transition supply, these drugs may not continue to be covered. Talk with your doctor about appropriate alternative medications. If there are none on the formulary, you or your doctor can request a formulary exception.

If you live in a long-term care facility, UnitedHealthcare will cover up to a temporary 31-day transition supply (unless your prescription is for less than 31 days or the drug is limited to a smaller dispensing amount). UnitedHealthcare will cover more than one refill of these drugs for the first 90 days for plan members, up to a 98-day supply. If you need a drug that is not on the formulary or your ability to get your drugs is limited, but you are past the first 90 days of plan membership, the transition program will cover a 31-day emergency supply of that drug (unless your prescription is for less than 31 days) while you pursue a formulary exception.

You may face unplanned transitions after the first 90 days of plan enrollment, such as hospital discharges or level of care changes (i.e., changing a long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care). If you are prescribed a drug that is not on the formulary or your ability to get your drugs is limited, you are required to use the plan's exception process. You can request a one-time emergency supply of up to 31 days (unless you have a prescription for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

 

Continuing members

As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). You may notice that a formulary medication you are currently taking is either not on the upcoming year's formulary or its cost sharing or coverage is limited in the upcoming year.

If your existing medication is subject to new formulary restrictions and you have not discussed switching to an alternative formulary medication or pursued a formulary exception with your doctor, you may be able to receive a temporary 31-day supply when you go to a network pharmacy to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care) that can occur anytime. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is limited, you are required to use the Plan's exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility and need an emergency supply, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days).

If you have any questions about this transition policy or need help asking for a formulary exception, a UnitedHealthcare representative can help.

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