If Your Drug is Not on the Formulary
You may be taking a drug that is not covered on the formulary (list of drugs) for your new Part D plan when you
- enroll in a Part D plan for the first time
- change to a different Part D plan
- move into or out of a long-term care facility
If so, you may be able to receive a limited supply of this non-formulary drug to help you transition to the drugs available on the new Part D plan. For 2010, this transition coverage is available if you
- switched from one plan to another after January 1, 2010
- enrolled in a new plan during open enrollment held November 15 - December 31, 2009, and your coverage is effective January 1, 2010
- are newly-eligible for Medicare during 2010 and were covered by another plan immediately before enrolling in a Part D plan
- move into or out of a long-term care facility during 2010
Please note: you are not eligible for transition coverage if you stay in the same Part D plan, even if the formulary changes for your Part D plan.
How Transition Coverage Works
During your first 90 days in the Part D plan, you may receive a one-time 30-day transition supply of a non-formulary drug. This will give you time to talk to your doctor about other medications you may take that are included in the formulary for your plan.
If you are in a long-term health care facility, you may receive one transition supply of up to 31 days. In addition, the plan may cover two refills until the end of the 90-day transition period.
This transition supply is only available for
- non-formulary drugs covered by Medicare
- formulary drugs that are subject to prior authorization, quantity limits or step therapy that were not required by your previous plan
For the Copayment Plan only, you will pay for this transition supply
- the non-preferred brand name (Tier 3) copayment for non-formulary drugs
- the tier listed in the formulary for drugs subject to prior authorization, quantity limits or step therapy
If Your Drug is No Longer on the Formulary
If you find out that your drug will no longer be on the formulary, you should talk with your doctor who prescribed the non-formulary drug about
- changing from a non-formulary drug to an alternative drug that is included on the formulary
- getting any prior authorizations that may be required for certain medications
- requesting a coverage determination or formulary exception for a non-covered drug by completing and submitting a coverage determination form
It is your responsibility to check the formulary before going to the pharmacy to get your prescription filled. Select the formulary for your plan
You should check and make sure that
- your medications are covered by your Part D plan
- you are aware of any prior authorizations or step therapy that may be required
- you are aware of any quantity limits
If you have any questions, please contact Customer Care.