If your drug is not on the Drug List or is restricted, here are things you can do:
You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
You can change to another drug.
You can request an exception and ask the Plan to cover the drug or remove restrictions from the drug.
You may be able to 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 provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
The drug you have been taking is no longer on the Plan’s Drug List.
The drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below:
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary supply of the drug during the following situations described below:
For those members who were in the Plan last year and aren’t 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 if your claims history shows you were previously on the drug and Highmark Wholecare made formulary changes from the previous year that negatively impacted you. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of the calendar year.
For those members who are new to the Plan and aren’t 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 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of a beneficiary’s enrollment in the plan, beginning on the effective date of coverage.
For those members who are new to the Plan and reside in a long-term care facility:
We will cover a 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 31 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 31 days during the first 90 days of a beneficiary’s enrollment in the plan, beginning on the effective date of coverage.
For those members who have been in the Plan for more than 90 days and reside in a long-term care facility and need a supply right away:
We will cover one 31-day supply, or less if your prescription is written for fewer days while an exception or prior authorization is requested. This is in addition to the above long-term care transition supply.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the Plan or ask the Plan to make an exception for you and cover your current drug. The sections below tell you more about these options.
You can change to another drug
Start by talking with your provider. Perhaps there is a different drug covered by the Plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you.
You can ask for an exception
You and your provider can ask the Plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the Plan to cover a drug even though it is not on the Plan’s Drug List. Or you can ask the Plan to make an exception and cover the drug without restrictions.
If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for next year. You can ask for an exception before next year and we will give you an answer within 72 hours after we receive your request (or your prescriber’s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect.