Medicare Matters. Amerihealth 65 for medicare Beneficiaries

Drug Formulary

Transition Process

What if my current prescription drugs are not on the formulary or are limited on the formulary?

New Members

As a new member in our plan, you might currently be taking drugs that are not on our formulary, or they are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you might be eligible to receive an initial 34-day transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 34-day transition supply, we may not continue to pay for these drugs under the transition policy.

If you are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Continuing Members

As a continuing member in the plan, you will receive your Annual Notice of Change (ANOC) by October 31. You may notice that a formulary medication that you are currently taking is either not on the upcoming year’s formulary or its cost-sharing or coverage is limited in the upcoming year.

In this case, we will provide a transition period consistent with the above transition process for new enrollees.

Change in level of care:

  • Members who have a change in level of care (setting) will be allowed a one-time, 34-day transition supply per drug.
  • If patients have more than one change in level of care in a month, the pharmacy will have to call the plan for an extension.

If you have any questions about our transition policy or need help asking for a formulary exception, call Member Services at the number printed on the back of your ID card, 8 a.m. to 8 p.m., seven days a week.