Prescription Drug Transition Policy

What can I do if my drug is not on Health New England’s formulary or if the drug is restricted in some way?

You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply).
(Click on the plus sign to expand our menu.)

This will give you and your provider time to change to another drug or to file a request to have the drug covered. Alternatively, you may change to another drug. Ask your doctor about other options that will work for you. Your other option is to file an exception and ask the plan to cover the drug or remove restrictions from the drug.

How can I get a temporary supply of my drug?

Under certain circumstances, we can offer a temporary supply of a drug to you. To be eligible for a temporary supply, you must meet the
two requirements below: (Click on the plus sign to expand our menu.)

The drug you have been taking is not on your plan’s formulary or is now restricted in some way.
You must be in one of the situations described below:

For those members who were in the plan last year and aren't in a long-term care facility, we will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply or less if your prescription is written for fewer days.
For those members who were in the plan last year and aren't in a long-term care facility, we will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
For those members who are new to the plan and reside in a long-term-care facility, we will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply), or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
For those members who have been in the plan for more than 90 days and reside in a long-term care facility, we will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

Am I eligible for an exception so that I can get my drug?

Exceptions are available if you have experienced a change in the level of care you are receiving which requires you to transition from one facility or treatment center to another. Examples of situations in which you would be eligible for the one-time temporary fill exception when you are outside of the three month effective date into the Part D program are as follows: (Click on the plus sign to expand our menu.)

If you were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital.
If you end your skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and need to revert back to your Part D plan formulary.
If you give up Hospice Status to revert back to standard Medicare Part A and B benefits.
If you are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized.

All of these situations would warrant a temporary one-time fill exception regardless of whether you are in your first 90 days of program enrollment. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you by filling out the following OptumRx Coverage Determination Request Form.