Transition policy - Chapter 8, 2021 UnitedHealthcare Administrative Guide

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.

The following table summarizes the rules for receiving a transition supply of a drug. Members should read their plan’s evidence of coverage (EOC) for details.

Transition eligible situations:

• 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 LTC facility and need a supply right away. At least a 31-day supply, as described in 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 a hospital 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 1-800-711-4555.