What to do if your drugs aren't on the drug list (formulary) or are restricted in some way
Sometimes, you may take a prescription drug that isn't on your plan's drug list or it's restricted in some way. Whether you're a new member or a continuing member, there's a way to get help.
Start by talking to your doctor. Your doctor can help decide if there's another drug on the drug list you can switch to. If there isn't a good alternative drug, you, your representative or your doctor can ask for a formulary exception. If the exception is approved, you can keep getting your current drug for a certain period of time.
Review your Evidence of Coverage (EOC) to find out exactly what your plan covers. If you’re a continuing member, you’ll get an Annual Notice of Changes (ANOC). Review the ANOC carefully to find out if your current drugs will be covered the same way in the upcoming year.
Whether you’re switching drugs or waiting for an exception approval, you may be eligible for a transition supply of your current drug.
- You must get your 1-month supply, as described in EOC, during the first 90 days of membership with the plan as a new member OR within the first 90 days of the calendar year if you are a continuing member and your drug has encountered a negative formulary change.
- You may also be eligible for a one-time, temporary 1-month supply if you qualify for an emergency fill while residing in a long-term care (LTC) facility after the first 90 days as a new member or you have encountered a level of care change.
- If your doctor writes your prescription for fewer days and the prescription has refills, you may refill the drug until you’ve received at least a 1-month supply, as described in your EOC.