Prescription Drug 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 in our plan, you may currently be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception.

If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 31-day supply (unless you have a prescription written for fewer days) of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written 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, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.

If you are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan, up to a 98-day supply. If you need a drug that is not on our formulary or your ability to get drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for less than 31 days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. 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.

 

Continuing members

As a continuing member in the plan, you receive an Annual Notice of Change (ANOC). You may notice that a formulary medication which 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.

For coverage requests we receive before December 16, 2013 and approve, the plan will cover the drug as of January 1, 2014. For coverage requests initiated on or after December 16, 2013, normal timeframes for resolution apply: you will receive an answer within 24 hours for urgent requests and 72 hours for all other requests.

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, as of January 1, 2014, you may receive a temporary 31-day supply (unless you have a prescription for less than 31 days), 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., in the week before a long-term care discharge) 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, 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 our transition policy or need help asking for a formulary exception, please contact UnitedHealthcare Customer Service.

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