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Transition Policy

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 (drug list), 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 and your doctor are determining your course of action, you may be eligible to receive at least a 30-day transition supply of the drug anytime during the first 90 days you are a plan member.

For each of your drugs that is not on the formulary or if your ability to get your drugs is limited, we will cover at least a 30-day supply when you go to a network pharmacy. If the prescription is written for less than 30 days, multiple fills are allowed to provide at least 30 days of drugs. After your transition supply, these drugs may not continue to be covered. 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 live in a long-term care facility, we will cover at least a temporary 31-day transition supply. We will cover more than one refill of these drugs for the first 90 days for plan members, for at least a 98-day supply. If you need a drug that is not on the formulary or your ability to get your drugs is limited, but you are past the first 90 days of plan membership, the transition program will cover at least a 31-day emergency supply of that drug while you pursue a formulary exception.

You may face unplanned transitions after the first 90 days of plan enrollment, such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care). If you are prescribed a drug that is not on the formulary or your ability to get your drugs is limited, you are required to use the plan's exception process. You can request a one-time temporary supply of at least 30 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.

Starting <October 15, 2017>, you may request a <2018> coverage review. If your request is approved, the plan will cover the drug as of <January 1, 2018>.

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, you may receive at least a 30-day temporary supply when you go to a network pharmacy to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you live in a long-term care facility, you may receive at least a 31-day supply of the transition eligible medication and can obtain multiple refills for at least a total of a 98-day supply, including when prescriptions are dispensed for less than the written amount due to drug utilization edits that are based on approved product labeling.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care) 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 temporary supply of at least 30 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 and need an emergency supply, we will cover up to at least a 31-day temporary supply.

If you have any questions about our transition policy or need help asking for a formulary exception, please contact a Customer Service representative.

 

Phone

1 (866) 231-7201 - Toll-Free
TTY users call toll-free 711

Fax

(888) 659-0618

Email

Memberservices@uhcsouthflorida.com

Mail

PO Box 56-5748
Miami, FL 33256