Transitions

What if my current prescription drugs are not on the formulary or are limited on the formulary?

2012 Transition Policy

If your drug is not on the Drug List or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your prescriber time to change to another drug or to file a request to have the drug covered.
• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your prescriber about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:
   • The drug you have been taking is no longer on the plan's Drug List.
   • The drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below:

   For those members who were in the plan last year and aren't in a long-term care facility:

   • We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum 30-day supply (or less if your prescription is written for fewer days). The prescription must be filled at a network pharmacy.

   For those members who are new to the plan and aren't in a long-term care facility:

   • We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30-day supply (or less if your prescription is written for fewer days). The prescription must be filled at a network pharmacy.

   For those members who are new to the plan and reside in a long-term care facility:

   • We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30-day supply (or less if your prescription is written for fewer days). The prescription must be filled at a network pharmacy.

   For those members who have been in the plan for more than 90 days and reside in a long-term care facility and need a supply right away:

   • We will cover one 31-day supply, (or less if your prescription is written for fewer days). This is in addition to the above long-term care transition supply.

   Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug.

   • For example, members who:
   1. Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours).
   2. Are discharged from a hospital to a home.
   3. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
   4. End a long-term care facility stay and return to the community.
   • If a member has more than one change in level of care in a month, the pharmacy will have to call our Plan to request an extension of the transition policy.

For more detailed information about your IU Health Plans (HMO) (HMOPOS) prescription drug coverage, please review your Evidence of Coverage and other plan materials.