Drug Transition Policy

New members in our plan may be taking drugs that are not on our Drug Formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover, or request a formulary exception in order to get coverage for the drug. While these new members might talk to their doctors to determine the right course of action, we may cover the non-formulary drug in certain cases during the first 90 days of new membership.

For each of the drugs that is not on our formulary or that have coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when the new member goes to a network pharmacy (and the drug is otherwise a "Part D drug"). After the first 30-day supply, we will not pay for these drugs, even if the new member has been a member of the plan less than 90 days.

If the new member 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). We will cover more than one refill of these drugs for the first 90 days for a new member of our plan. If a new member needs a drug that is not on our formulary or is subject to other restrictions, such as step therapy or dosage limits, but the new member is 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 the new member pursues a formulary exception.

Member Category	ESSENCE Process
Current enrollees experiencing a level of care change	Enrollees who are outside their transition period may experience circumstances that involve level of care changes in which a beneficiary is changing from one treatment setting to another. CMS encourages, but does not require, plans to incorporate processes in their transition plans that allow for transition supplies to be provided to current enrollees with level of care changes. Thus, beneficiaries and providers must avail themselves of plan exceptions and appeals processes.
Current enrollees entering long term care settings from other care settings	These enrollees will be provided emergency supplies of non-formulary drugs - including Part D drugs that are on a plan's formulary but require a prior authorization or step therapy under a plan's utilization management rules. This transition supply is not limited only to initial enrollment.
Current enrollees in a long term care setting requiring an emergency supply of non-formulary drug	To the extent that an enrollee in a long term care setting is outside his or her 90-day transition period, the plan must still provide an emergency supply of non-formulary Part D drugs - including Part D drugs that are on a plan's formulary but require prior authorization or step therapy under a plan's utilization management rules - while an exception is being processed. This emergency supply of non-formulary Part D drugs must be for at least 31 days of medication, unless the prescription is written by a prescriber for less than 31 days.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and that are purchased at a network pharmacy. The transition policy cannot be used to purchase a non-Part D drug or drug out-of-network.

In some cases, we will contact you if you are taking a drug that is not on our formulary. We can give you the names of covered drugs that are also used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.