Blue Cross Blue Shield of Michigan provides a transition process that allows members to receive a temporary supply of non-formulary drugs or to request a formulary exception on the grounds of medical necessity. This process meets the immediate needs of our members and provides sufficient time for them to work with their health care providers to switch to a therapeutically equivalent formulary medication or to complete the formulary exception process. The transition policy applies to Part D drugs that are not on BCBSM's formulary — and to Part D drugs that are on BCBSM's formulary, but require prior authorization or step therapy under the Blues' utilization management rules.
The transition policy applies to members in various settings:
Retail or mail pharmacy setting
A temporary 31-day supply (unless the prescription is written for less than a 31-day supply) of non-formulary drugs will be provided anytime during the 90-day transition period.
Long-term care setting
Multiple fills of a temporary 31-day supply (unless the prescription is written for less than a 31-day supply) will be provided during the 90-day transition period. BCBSM will honor multiple fills of non-formulary Part D drugs for up to a 93-day supply within the first 90 days of coverage in a BCBSM plan.
Level of care changes
An emergency transition supply will be provided to current long-term care enrollees who enter into a facility from another care setting. This transition supply is not limited to initial enrollment only.
After the 90-day transition period expires, BCBSM will also provide a 31-day transition supply to current long-term care enrollees who require an emergency supply of a non-formulary drug. The emergency supply will be granted while the enrollee's exception or prior authorization is being processed.
The transition policy applies to the following enrollees:
- New enrollees following the annual coordinated election period.
- Newly eligible Medicare beneficiaries from other coverage.
- Individuals who switch from one plan to another after the start of the contract year.
- Enrollees residing in long-term care facilities.
- Enrollees who change treatment settings due to a change in level of care.
- Current enrollees affected by formulary changes from one contract year to the next.
The transition period begins on the enrollee's effective date of coverage under the plan. Each enrollee who receives a transition supply will be sent a written notice via first-class U.S. mail. The notice will be sent within three days of the temporary fill. The notice will include:
- An explanation of the temporary nature of the transition supply.
- Instructions for working with the enrollee's prescriber and plan for identification of therapeutic alternatives that are on the formulary.
- An explanation of the enrollee's right to request a formulary exception.
- A description of the procedures for requesting a formulary exception.
Formulary exception request forms will be available to members, appointed representatives and physicians via mail, fax, email and our website.
To determine the proper course of action, Medical review of non-formulary drug requests may be required for enrollees receiving a temporary supply of a Part D drug under this policy. BCBSM will work with the enrollee's physician to gather appropriate clinical history to facilitate the non-formulary drug request or the switch to a therapeutically appropriate formulary alternative.
Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a drug that Medicare excludes from coverage or a drug from an out-of-network pharmacy, unless you qualify for out-of-network access. See your Evidence of Coverage for information about excluded drugs.