Drug Transition Policy | Allwell from Western Sky Community Care

Drug Transition Policy

 

If a drug you are taking is not on the List of Drugs (Formulary) or is restricted in some way, here are things you can do:

  • In some cases, you may be able to get a temporary supply of the drug (see below). The temporary supply will give you and your doctor time to change to another drug or to file a request to have the drug covered.
  • You can change to another drug that is on the List of Drugs (Formulary).
  • You can request an exception and ask us to cover the drug or remove restrictions from the drug.

In some cases and following CMS rules, we must offer you a temporary supply of your drug. A temporary supply helps your immediate need. It also gives you time to talk with your doctor about a dose change or another drug that we do cover, or to complete an exception request.

To receive a temporary supply, you must meet BOTH of the two rules below:

1.     The drug that you take:

  • Is not on our list of drugs OR
  • Is now limited in some way

(Chapter 5 in the Evidence of Coverage has more information.)

AND

2.     You are in one of these situations:

For Medicare Part D drugs:

You are new to the plan or were in the plan last year.

  • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new, and during the first 90 days of the calendar year if you were in the plan last year and had received the drug within the last 180 days.
  • This temporary supply will be for up to 30 days at a retail pharmacy and 31 days at a long-term care pharmacy.
  • If your prescription is written for fewer days, we will allow refills to provide up to 30 days at a retail pharmacy and 31 days at a long-term care pharmacy. You must fill the prescription at a network pharmacy. (Please note, a long-term care pharmacy may provide your prescription drug in small amounts at a time to prevent waste.)

You live in a long-term care facility and need a supply right away.

  • We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the section above.

If your level of care changes, we will cover a temporary supply of your drugs. A level of care change happens when you are released from a hospital.  It also happens when you move to or from a long-term care facility.

You are moving from a long-term care facility or a hospital stay to home and need a temporary supply right away:

  • We will cover one 30-day supply, or less if your prescription is written for fewer days. In this case, we will allow refills up to a total of 30-days.

You are moving from home or a hospital stay to a long-term care facility and need a temporary supply right away:

  • We will cover one 31-day supply, or less if your prescription is written for fewer days. In this case, we will allow refills up to a total of 31-days.

To ask for a temporary supply of a drug, contact Member Services.

For low-income subsidy (LIS)-eligible members, the cost-sharing for a temporary supply will never exceed the maximum copayment amount.

After you get your temporary supply

Within three business days after you receive your temporary supply, you and your doctor will receive a letter that explains what to do next. You should talk with your doctor to decide what to do before your supply runs out. You can:

  • Change to another drug. We could have other drugs on the List of Drugs (Formulary) that might work for you. You can contact Member Services to ask for this list. Share it with your doctor to decide if there is an effective alternate drug.
  • Ask for an exception. You or your doctor can ask us to make an exception or submit a request for coverage determination. For example, you can ask us to cover a drug even though it is not on our list of drugs. Or you can ask us to cover the drug without limits.

If you have questions, please contact Member Services.