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Pharmacy Transition Plan

General Transition Notice

Sometimes, we will cover a short-term supply of a medicine you take that’s not on the Drug List. This usually happens when you join our plan and are taking medicines not on the Drug List. Or, you might be discharged from a hospital with medicines that are not on the Drug List (see more details below). Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply,
these two things must be true:

1.The medication you have been taking must be either:

  • Not on our Drug List
  • On our Drug List, but prior authorization or step therapy is needed

2.You must be in one of these situations:

  • You were in the plan last year. You aren’t in a long-term care facility. We will cover a temporary supply of your medicine during the first 93 days of the membership. This temporary supply will be for a maximum of 31 days. If the prescription is written for fewer days, multiple fills are allowed to provide the maximum limit of a 31-day supply. The prescription must be filled at a network pharmacy.
  • You’re new to the plan. You aren't in a long-term care facility. We will cover a temporary supply of your medication one time only during the first 93 days of your membership in the plan. This temporary supply will be for a maximum of 31 days. If your prescription is written for fewer days, multiple fills are allowed to provide the maximum limit of a 31-day supply. The prescription must be filled at a network pharmacy.
  • You’re new to the plan. You’re in a long-term care facility. We will cover a temporary supply of your medication during the first 93 days of your membership in the plan. The total supply will be for up to a 93-day supply depending on the dispensing increment. If needed, we will allow multiple refills to provide up to the maximum 93-day supply.
  • You’ve been in a long-term care facility for more than 93 days and need a supply right away.We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
  • Your level of care has changed. You might be able to get a one-time short-term (31-day) supply of your medicine if your level of care changes. That means you have to move from one facility or treatment center to another. We may cover this short-term supply after you’ve been a member for 90 days if you:

    • Were released from the hospital and given a list of discharge medicines based on the drug list the hospital uses
    • Ended your stay at a skilled nursing facility covered by Medicare Part A (where payments include all pharmacy charges) and need to switch back to our plan’s Drug List
    • Give up hospice status to switch back to standard Medicare benefits that you get under Cal MediConnect Part D

All of these are reasons we might cover a temporary one-time fill exception, even if you’ve been a member for more than 90 days.

Please call member services to ask for your temporary supply.

Our transition policy applies only to:

  • Part D medications and certain Medi-Cal covered medications
  • Medications purchased at a network pharmacy

While you’re getting a temporary supply of a medicine, talk with your provider to decide what to do when your medicine runs out. You can either:

  • Switch to a different medicine covered by the plan – search our Drug List
  • Ask us to make an exception for you and cover the medicine you’re taking now

H6229_17_30116_R CMS Approved 02/10/2017 Page Last Updated On 10/1/2018

Questions?
Need help understanding our transition policy? Want to ask for an exception? We can help.

Call Member Services at 1-855-817-5785
(TTY: 711).
We’re open Monday through Friday from 8 a.m. to 8 p.m. local time.