What to do if your current prescription drugs are not on the formulary or are limited on the formulary.
As a new member in our plan, you may 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, start by talking with your doctor about appropriate alternative medications available on our formulary. If no appropriate alternatives can be found, 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 an initial 30-day transition supply (unless your prescription is written for fewer days) of the drug anytime during the first 90 days you are a plan member.
For each of your drugs that are not on our formulary or if your ability to get your drugs is limited, we will cover a 30-day supply (unless your prescription is for fewer days) when you go to a network pharmacy. If the prescription is written for less than 30 days, multiple fills are allowed to provide up to a total of 30 days of drugs. After your first 30-day transition supply, these drugs may not continue to be covered. Talk with your doctor about appropriate alternative medications. If there are none on the formulary, you or your doctor can request a formulary exception.
If you live in a long-term care facility, we will cover a temporary 31-day transition supply (unless your prescription is for fewer days). We will cover more than one refill of these drugs for the first 90 days for plan members, 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 plan membership, the transition program will cover a 31-day emergency supply of that drug (unless your prescription is for fewer days) 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 a 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 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 emergency supply of up to 30 days to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.
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.
You can ask for an exception
You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan's drug list. Or you can ask the plan to make an exception and cover the drug without restrictions. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.
If you have any questions about our transition policy or need help asking for a formulary exception, please call Senior Dimensions' Customer Service toll-free at 1-800-650-6232, TTY 711. Customer Service hours: October 1 through February 14: 7 days a week, 8 a.m. to 8 p.m. local time. February 15 through September 30: Monday through Friday, 8 a.m. to 8 p.m. local time. On Saturday, Sunday and holidays, please leave a detailed message and a representative will return your call within a business day.