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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
  • You change to a different Part D plan
  • You 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 2012, this transition coverage is available if you

  • switched from one plan to another after January 1, 2012
  • enrolled in a new plan during open enrollment held October 15 - December 7, 2011, and your coverage is effective January 1, 2012
  • are newly-eligible for Medicare during 2012 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 2012.

How Transition Coverage Works

During the first 90 days you are enrolled in the Part D plan, you may receive up to a 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

  • during the first 90 days that you are enrolled in the plan, you may receive a transition supply of up to 31 days and  the plan may cover refills until the end of the 90-day transition period.
  • after 90 days, you may receive a transition supply of up to 31 days

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 decision or formulary exception for a non-covered drug by completing and submitting a coverage decision form

You may receive up to a 30-day transition supply of a drug that was removed from the formulary. This will give you time to talk to your doctor about an alternative drug.

It is your responsibility to check the formulary before going to the pharmacy to get your prescription filled. To find out if your drug is covered

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.