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 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.

·         -- or -- the drug you have been taking is now restricted in some way

2. You must be in one of the 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. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days, in which case PMC will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy. The current enrollee transition period covers the period from January 1 to March 31 of the contract 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  a 30-day supply, or less if your prescription is written for fewer days, in which case PMC will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.

This includes cases of a member disenrolls and then re-enrolls in a plan, that member would be eligible for transition

• For those who are a new member and a resident 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 31-day supply, or less if your prescription is written for fewer days, in which case PMC will allow multiple fills to provide up to a total of 30 days of medication. If needed, we will cover additional refills during your first 90 days in the plan. The current enrollee transition period covers the period from January 1 to March 31 of the contract year.

• 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 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

• For those members who have been discharged from a hospital psychiatric hospital or other level of care facility to home or if your ability to get your drugs is limited (preauthorization, step therapy, quantity limits).

We will cover one 30-day supply, of drugs not included on the Drug List. Cases for beneficiaries with level of care changes are managed in the Call Center unit once the pharmacy identifies to us that a claim reject is being reflected in the claim adjudication system

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 there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered.

            You can change to another drug

Start by talking with your doctor. 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 doctor to find a covered drug that might work for you.

You can file an exception

You and your doctor or other prescriber 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 doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber 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 and your doctor or other prescriber want to ask for an exception, please refer to your Evidence of Coverage.  It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.