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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 a drug that is not on our formulary. Or, the drug is on our formulary but your ability to get it is limited. In instances like these, you should 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 may be eligible to receive an initial 30-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 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary. If there are none, you or your doctor may request a formulary exception.

If you are a resident of a long-term care facility, we will cover a temporary, 31-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 if 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 31-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 should have received your Annual Notice of Change/Evidence of Coverage (ANOC/EOC) 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 that coverage is limited in the upcoming year.

You may currently be taking drugs that in 2009 may require prior authorizations (approval in advance), and/or have quantity limit restrictions. In instances like this, 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.

If you have any questions about our transition policy or need help asking for a formulary exception, call Customer Service at the number printed on the back of your ID card.