Transition policy - Chapter 8, 2022 UnitedHealthcare Administrative Guide

Our transition policy allows for a 1-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 Temporary transition supply amount

New members: During the first 90 days of membership in the plan

Continuing members: During the first 90 days of the calendar year if the drug encountered a negative formulary change

At least a 1-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 unplanned transitions such as hospital discharges (including psychiatric hospitals) or level of care changes (i.e., changing long-term care facilities, exiting and entering a long-term care facility, ending Part A coverage within a skilled nursing facility or ending hospice coverage and reverting to Medicare coverage) at any time during the plan year At least a 1-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.