What if my prescription isn’t on the drug list or has new restrictions?
Who is this for?
If you're a new or current member of our Medicare Advantage plans, this explains how our transition policy helps you get the medication you need.
We know it's scary to lose coverage for a prescription you count on. Or wonder how you'll afford the cost of a drug your plan doesn't cover.
That's why we have a transition policy for Medicare Part D prescription drugs. It gives you time to work with us and your doctor when:
- Your prescription isn't on your plan's drug list.
- Your prescription was taken off of your plan's drug list.
- Your prescription requires approval or has restrictions it didn't before, like prior authorization or step therapy.
How will you know the status of your prescription has changed? We'll send you and your doctor a letter.
How does the transition policy work?
When it starts
If you just enrolled in your plan, your 90-day transition period begins when your coverage starts. If you're already a plan member, your 90-day transition period starts at the beginning of the plan year.
Steps you can take
You have options if your plan doesn't cover a Part D prescription drug or it has additional restrictions. During your 90-day transition period you can:
- Talk to your doctor about finding an alternative to the prescription that isn't on your plan's drug list.
- Go through any required approval process.
- Ask us to make an exception and cover a prescription not on our drug list or increase a quantity limit. You do this by sending us a coverage determination form. Generally, we give you a decision in less than 72 hours.
In the meantime
During your 90-day transition period, in most cases we'll cover at least one fill or refill of the prescription. It can be up to a month's supply from a retail or mail order pharmacy in our network.
Our transition policy provides additional help under some circumstances. They include entering or leaving a long-term care facility like a nursing home, or when you're discharged from the hospital. So you can get a medication while we work through the approval process, we'll:
- Cover multiple refills of your prescription during the 90-day transition period, up to a month's supply at a time.
- Cover a month's supply outside of the 90-day transition period in some situations.
If you have more questions about our transition policy, call the Customer Service number on the back of your Blues ID card and we'll help.