What should I do if I'm taking a drug that isn't on the formulary or needs authorization?

Always talk to your doctor right away when you find out you take a drug that will not be on the formulary or one that requires prior authorization. If you are unable to change your drug to one on a formulary or obtain authorization in time, we will cover a temporary supply of eligible exception medications according to the following transition policy guidelines:

Eligible transition medications are those that:

1. Are covered under Medicare Part D but are not included on our formulary, or
2. Are on our formulary with prior authorization or step therapy requirements.

Note:   All transition medications must be obtained from a network pharmacy.

• We will cover a temporary supply of eligible exception medications during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. No further refills will be covered unless and exception is approved. More information regarding the exceptions process.
• Members living in long-term care facilities — We will cover a temporary supply of eligible exception medications during the first 90 days of your membership in the plan. The total supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you have been enrolled in our plan for more than 90 days, refills of non-covered medications will not be covered after the first temporary supply.
• Members who were enrolled in a Health First Health Plans as previously may receive a transitions fill.
  • If your drug was removed from the formulary as of January 1 of the new plan year. — If you are taking a formulary medication that is no longer covered on January 1, of the new plan year,  we will cover a temporary supply of eligible exception medications for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. This temporary supply of up to 30 days must be filled between January 1 and March 31, of the new plan year. This will provide you with a temporary supply while you talk to your doctor and transition to a covered alternative or pursue an exception. After your one time supply, no further refills will be covered unless an exception is approved. More information regarding the exceptions process.
  • If your formulary exception was not honored as of January 1, of the new plan year — If your formulary exception expired on December 31, of the plan year   we will cover a temporary supply of eligible exception medications for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medications. This temporary supply of up to 30 days must be filled between January 1 and March 31, of the new plan year. After your one time supply, no further refills will be covered unless an exception is approved. More information regarding the exceptions process.
• If you have a change in treatment settings (for example you move from a hospital to your home) — We may cover up to one 30-day supply of exception medications if you have been prescribed a non-covered drug as a result of changing from one treatment setting to another. An example of a change in treatment setting is being discharged from a hospital or a skilled nursing facility to return home. Please Customer Service Representative for additional information.

Note: If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Tier 4.

The temporary transition supplies are provided in order to give you to time to talk to your doctor about switching to an appropriate formulary drug, obtaining authorization, or requesting a formulary exception. Health First Health Plans will also send letters to members who were given a temporary supply.  If you have any questions about this policy, please Customer Service Representative.

Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.

Y0089_EL108008_M | Accepted date: 10/01/2023
Last updated: 10/01/2023