Prescription Drug Transition Policy

Transition Fills

If your drug is not on the Drug List (Formulary) or is restricted, you may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage.

To be eligible for a temporary supply, you must meet the two requirements below:

The change to your drug coverage must be one of the following types of changes: (1) the drug you have been taking is no longer on the plan’s Drug List or (2) the drug you have been taking is now restricted in some way.
You must be in one of the situations described below:
- For those members who were in the plan last year and are not in a long-term care facility. We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy
- For those members who are new to the plan and are not in a long-term care facility. We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days.
- For those who are new members and are residents in a long-term care facility. We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
- For those who have been a member of the plan for more than 90 days and are a resident of a long-term care facility and need a supply right away. We will cover one 30-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

If you are a current member affected by level of care changes, we will provide a temporary supply of the non-formulary drug during the first 90 days after your level of care changes or provide you with the opportunity to request a formulary exception in advance for the following year. Please note that our transition policy applies only to those drugs that are “Part D drugs” and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access.

To ask for a temporary supply, call Optum Customer Service at 844-368-3139 (TTY users should call the State Relay Service number at 711) available 24 hours a day, 7 days a week.

During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps you can change to an alternative drug covered by Senior Care Plus formulary or you and your doctor can ask for a formulary exception. If you have any questions for Senior Care Plus regarding Part D transition policy, please contact Customer Services using the contact information below.