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Transition Policy - Chapter 7, 2019 UnitedHealthcare Administrative Guide

Our transition policy gives temporary coverage to new members who have an immediate need for a drug not on our formulary, subject to restriction, or no longer covered. You should switch the member to a different drug or request a formulary exception. We may provide the member with a temporary transition supply while you pursue an exception. The drug must be a Part D drug purchased at a network pharmacy.

Note:

  • Only formulary changes that take effect at the beginning of the year are subject to the Transition Policy. There is a separate process for changes to the formulary that occur mid-year.
  • Members subject to formulary changes in the middle of the year receive a 60 day notice prior to the change. During that time we will cover the prescribed drug while the member coordinates with the care provider to either switch to another drug or request an exception.

The following summarizes the rules for receiving a transition supply of a drug:

Retail Pharmacy (Not in a Long Term Care Facility)

  • Current Member (>90days): Length of the prescription, with refills, up to a maximum of 30 or 31 days total, depending on the plan. During the first 90 days of plan calendar year only.
  • New Member (<90 days): Length of the prescription, with refills, up to a maximum of 30 or 31 days total, depending on the plan. During the first 90 days of the plan calendar year only.

Long Term Care Facility Pharmacy

  • Current Member (>90days): Length of the prescription, with refills, up to a maximum of 31 days total. During the first 90 days of the plan calendar year only.
  • New Member (<90 days): Length of the prescription, with refills, up to a maximum of 31 days total. During the first 90 days of the plan calendar year only.

To request a formulary exception call our Pharmacy Department at 800-711-4555 or fax us at 800-527-0531.