Prescription Drug Transition Process | AARP® Medicare Plans from UnitedHealthcare®
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Medicare Advantage Plans

Prescription Drug Transition Process

What to do if your current prescription drugs are not on the formulary or are restricted in some way. 

 

New members

As a new member of an AARP® MedicareComplete® plan, insured through UnitedHealthcare, you may currently be taking drugs that are not on the UnitedHealthcare® Drug List, or are on the Drug List but coverage is restricted in some way.

Under certain circumstances, you may be able to get a temporary supply of your prescription drug. This will give you and your doctor time to change to another drug or request an exception and ask to cover the drug or remove restrictions from the drug. If the exception is approved, you will be able to obtain the drug for the specified period of time.

While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 31-day supply of the drug anytime during the first 90 days you are a member of the plan. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31-day supply. The prescription must be filled at a network pharmacy.

After your first 31-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on the plan's Drug List and if there are none, you or your doctor can request an exception.

If you are a resident of a long-term care facility, UnitedHealthcare will cover a temporary supply of your drug during the first 90 days of your membership in our plan. The total supply will be for a maximum of a 98-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 98-day supply. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

If you reside in a long-term care facility and need a drug that is not on the Drug List or coverage is restricted in some way, but you are past the first 90 days of membership in a plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for less than 31 days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing a long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care) that can occur after the first 90 days that you are enrolled as a member of a plan. If you are prescribed a drug that is not on the Drug List or coverage is restricted in some way, you may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor to pursue an exception. This is in addition to the above long-term care transition supply.

 

Continuing members

As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). This will tell you about any change in the coverage for your drug for next year.

Starting October 15, 2015, you may request a 2016 coverage review. If your request is approved, the plan will cover the drug as of January 1, 2016.

If a drug you are taking will be removed from the formulary or restricted in some way for next year, you can work with your doctor to find a different drug that we cover.  If there is no alternative, you or your doctor can request a formulary exception. We will allow you to request a formulary exception in advance for next year. You may request a formulary exception starting October 15, 2015 and we will give you an answer within 72 hours after we receive your request (or your prescriber's supporting statement).  If your request is approved, we will cover the drug as of January 1, 2016 for the specified period of time.

If you have not discussed with your doctor to switch to an alternative formulary medication or pursued a formulary exception, you are eligible to receive a temporary 31-day supply of your drug as of January 1, 2016. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31-day supply. The prescription must be filled at a network pharmacy. After your 31-day transition supply, we may not continue to pay for your drug under the transition policy. You are reminded to work with your doctor to find a different drug that we cover or you or your doctor can request an exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Part D coverage or when taken off of hospice care) that can occur anytime. If you are prescribed a drug that is not on our Drug List or coverage is restricted in some way, you are required to use the plan's exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days).

If you have any questions about this transition policy or need help asking for a formulary exception, a UnitedHealthcare representative can help.

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