Our transition policy allows for a one-month coverage for 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.
- New members must get their one-month supply, as described in their Evidence of Coverage (EOC), during the first 90 days with the plan.
- Continuing members must get their one-month supply within the first 90 days of the calendar year if the drug has encountered a negative formulary change.
- After the first 90 days as a new member, or if a member has a change in level of care, they may be eligible for a one-time, temporary one-month supply if they qualify for an emergency fill while residing in a long-term care (LTC) facility.
The following summarizes the rules for receiving a transition supply of a drug. Members should read their plan’s EOC for details.
Transition Eligible Situations / Temporary Transition Supply Amount
- New Members: During the first 90 days of membership in the plan. / At least a one-month supply, as described in member’s EOC.
- Continuing Members: During the first 90 days of the calendar year if the drug encountered a negative formulary change. / .At least a one-month supply, as described in member’s EOC.
- For members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away. / At least a 31-day supply, as describedin the member’s EOC.
- Members who have a level of care change at any time during the plan year (i.e., going into a LTC facility from a hospital, going home from ahospital stay, or going home from an LTC facility stay). / At least a one-month supply, as described in member’s EOC.
To request a formulary exception, you may use the online tool at professionals.optumrx.com or call our Pharmacy Department at 800-711-4555.