Transition Policy

New members in our Plan may be taking drugs that aren't in our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage in order to get coverage for the drug. See Section 10 of the Evidence of Coverage (under "What is an exception") to learn more about how to request an exception. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior or step therapy or will no longer be on our formulary next year, and you need help switching to an appropriate drug that we cover or requesting a formulary exception.

During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year provide you with the opportunity to request a formulary exception in advance for the following year.

For each of the drugs that isn't on our formulary or that has coverage restrictions or limits, we will cover a temporary 30 day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is otherwise a "Part D drug". After we cover the temporary 30 day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31 day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31 day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

In circumstances where a beneficiary is changing from one treatment setting to another, MD Care will ensure a fast process for approving non-formulary Part D drugs. This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes are; beneficiary who are discharged from a hospital to a home; beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary; beneficiaries who end a long-term care facility stay and return to the community; and beneficiaries who are discharged from psychiatric hospitals with medication regimens that are highly individualized.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and that are bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access.