PDP Prescription Transition Policy

For Basic(PDP) plan

What should I do if I’m taking a drug that isn’t on the formulary or needs authorization?

Always talk to your doctor right away when you find out you take a drug that will not be on the formulary or one that requires prior authorization. If you are unable to change your drug to one on a formulary or obtain authorization in time, we will cover a temporary supply of eligible exception medications according to the following transition policy guidelines:

Eligible transition medications are those that:

  1. are covered under Medicare Part D but are not included on our formulary, or
  2. are on our formulary with prior authorization or step therapy requirements.

Note: All transition medications must be obtained from a network pharmacy.

  • New members (within 90 days of the initial enrollment date) — We will cover up to one (1) 30-day supply of the eligible exception medications that were prescribed to you before you enrolled in our plan. No further refills will be covered unless an exception is approved.
  • Members living in long-term care facilities — We will cover up to one (1) 31-day supply of eligible exception medications, even if they are prescribed after you enrolled in our plan. If you are a new member (within 90 days of initial enrollment), we will also cover more than one (1) refill during the first 90 days of your membership up to a 93-day supply. If you have been enrolled in our plan for more than 90 days, refills of non-covered medications will not be covered after the first temporary supply.
  • Members who were enrolled in a Health First Health Plans as of December 31, 2013:
    • If your drug was removed from the formulary as of January 1, 2014 — If you are taking a formulary medication that is no longer covered on January 1, 2014, we will cover up to one (1) 30-day supply of your medication. This one time supply of up to 30 days must be filled between January 1, 2014 and March 31, 2014. This will provide you with a temporary supply while you talk to your doctor and transition to a covered alternative or pursue an exception. After your one time supply, no further refills will be covered unless an exception is approved.
    • If your formulary exception was not honored as of January 1, 2014 — If your formulary exception expired on December 31, 2013, we will cover up to one (1) 30-day supply of your medication.  This one time supply of up to 30 days must be filled between January 1, 2014 and March 31, 2014. After your one time supply, no further refills will be covered unless an exception is approved.
  • Members who change treatment settings (for example you move from a hospital to your home) — We may cover up to one (1) 30-day supply of exception medications if you have been prescribed a non-covered drug as a result of changing from one treatment setting to another. An example of a change in treatment setting is being discharged from a hospital or a skilled nursing facility to return home. Please contact customer service for additional information.

Note: Your cost for transition supplies will be at the highest drug cost-share (highest tier) under your plan. Tiering exceptions cannot be made for the cost of these transition medications.

The temporary transition supplies are provided in order to give you to time to talk to your doctor about switching to an appropriate formulary drug, obtaining authorization or requesting a formulary exception. Health First Health Plans will also send letters to members who were given a temporary supply. If you have any questions about this policy, please contact our Customer Service Department.


Y0089_MP3537 Approved 11/06/2013
Last updated: 10/1/2013