New members in our Plan may be using drugs that are subject to certain restrictions, such as prior authorization.
Please contact our Customer Service Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (toll free) or TTY 1-866-627-8182 (people with hearing disabilities), service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Services hours from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m., if your drug is subject to certain restrictions, and you need help to request an organizational determination.
Under certain circumstances, we must provide a temporary supply of a drug that you are already using. This temporary supply gives you time to consult with your provider about the required information to meet our prior authorization criteria.
To be eligible for a temporary supply, the drug you have been using should be subject to certain restrictions, such as prior authorization.
If you are a new member and you are undergoing an active course treatment, even if the service is provided by an out-of-network provider we will cover a temporary supply of your drug during the first ninety (90) days of your membership in the plan, as long as a history of prior use of the drug is received.
When we provide a temporary supply of a drug that has coverage restrictions or limits (but is otherwise considered a “Part B drug”), we will cover a 90-days maximum temporary supply. If the prescription is prescribed for fewer days, we will allow multiple fills to provide up to a maximum of 90 days of the drug. After we cover the temporary 90-days supply, we generally will not pay for this drug as part of our transition policy again. We will send you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an organizational determination or an exception to our pre- authorization criteria and how to work with your provider to submit the required information.