Plan Transition Policy for Prescription Drugs

 

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:
 

1. The change to your drug coverage must be one of the following types of changes:

o The drug you have been taking is no longer on the plan’s Drug List (formulary).

o or the drug you have been taking is now restricted in some way

2. 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. The prescription must be filled at a network pharmacy.

For those members who are new to the plan 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 your membership in the plan. 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 who are a new member and a resident 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 who have been a member of the plan for more than 90 days and are a resident of 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 above long-term care transition supply.

For those existing members whose drug has changed tier: You can contact us to request a tiering exception or switch to an alternative drug listed on ourDrug List (formulary) with your physician’s help.

o To ask for a temporary supply, call Customer Service.

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 and cover the drug in the way you would like it to be covered.

For those members with Level of Care Changes: If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a one-time temporary supply for up to 30 days (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. During this period, you can discuss alternative treatments with your doctor or use the plan’s exception process if you wish to continue coverage of the drug after the temporary supply is finished. Our transition policy will not cover drugs that Medicare does not normally cover, such as benzodiazepines or barbiturates.

Transition Fill Notice

Blue Cross & Blue Shield of Rhode Island is a Medicare Advantage organization with a Medicare contract.

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