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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 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 are talking with your doctor to determine your course of action, you are eligible to receive at least an initial 30-day supply (unless you have a prescription written for fewer days) of the drug anytime during the first 90 days you are a member of our plan when you go to a network pharmacy.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover at least a temporary 30-day supply (unless you have a prescription written for less than 30 days) 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 a total of 30 days supply of drug. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. 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 are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan, up to a 98-day supply. If you need a drug that is not on our formulary or your ability to get drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for less than 31 days) while you pursue a formulary exception.

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 after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is limited, you may request a one-time supply of up to 30 days (unless you have a prescription written for less than 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.

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, as of January 1, 2017, you may receive at least a temporary 30-day supply (unless you have a prescription for less than 30 days), when you go to a network pharmacy, to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

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 supply of up to 30 days (unless you have a prescription written for less than 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, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days).

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