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 may currently be taking drugs that are not on our formulary, or they may be on our formulary but your ability to get them is limited. In instances like these, 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 transition supply of the drug during the first 90 days you are a member of our plan. Outside the first 90 days transition, a member may be eligible for a 10-day temporary supply to allow them enough time to work with the prescriber to change medications or complete an exception request based on medical necessity.
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 up to a 34-day temporary supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 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 34-day temporary transition supply, and refills during 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 up to a 34-day emergency supply of that drug 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 31st each year. If you notice that a formulary medication 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 you can submit a Formulary Exception Request after January 1, 2008.
You can submit Formulary Exception Request to CCHP, 595 Center Ave, Suite 100, Attention Pharmacy Services, Martinez, CA 94553.
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. For example, members who:
- Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours).
- Are discharged from a hospital to a home.
- End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
- End a long-term care facility stay and return to the community.
- If a member has more than one change in level of care in a month, the pharmacy will have to call the plan to request an extension of the transition policy.
Please note that our transition policy applies only to those drugs that are "Part D drugs" and that are purchased at a network pharmacy. The transition policy cannot be used to purchase a non-Part D drug or drugs from an out-of-network pharmacy.
If you have any questions about our transition policy or need help asking for a Formulary Exception Request, call Pharmacy Services 8:00 a.m. to 8:00 p.m., seven days a week at 1-877-661-6230 (press 3), California Relay/ TTY/TDD 1-800-735-2929.
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