Drug Transition Policy
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 alternative 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 30 day supply (unless you have a prescription written for fewer days). After your first 30 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93 day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
For members who have a change in their level of care setting, Essence will cover a temporary 34 day supply (102 day supply for members entering a long term care facility) of non-formulary Part D drugs.
Please note that our transition policy applies only to those drugs that are "Part D drugs". Members are entitled to receive a transition supply from a Network Pharmacy or an Out-of-Network Pharmacy. If you obtain your medication from an Out-of-Network Pharmacy you might be required to pay for the medication and ask us to reimburse you.
If you are taking a drug that is not on our formulary we might contact you and give you the names of drugs on our formulary that are also used to treat your condition. You can ask your doctor if any of these drugs are an option for your treatment.