New members in our Plan may be using drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception to get coverage for the drug. For more information on how to request an exception, refer to Chapter 9 of your Evidence of Coverage
– Can also refer to the section. “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”
Please contact our Service Customer Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (toll free number) 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 not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.
Under certain circumstances, we must provide a temporary supply of a drug that you are already taking. This temporary supply gives you time to talk with your provider about the change in coverage and decide what to do.
To be eligible for a temporary supply, the drug you have been taking must no longer be on the plan’s Formulary OR is now restricted in some way.
If you are a new member, we will cover a temporary supply of your drug during the first ninety (90) days of your membership in the plan.
If you are a current member affected by a formulary change from one year to the next, we will cover a temporary supply of your drug during the first ninety (90) days of the calendar year and we will provide you with the opportunity to request a formulary exception in advance for the following year.
When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day maximum temporary supply. If the prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medication. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
For those members who have been in the plan for more than 90 days and reside in a long-term-care facility (like a nursing home) and need a supply right away, we will cover a one 31-day emergency supply for a particular drug (unless the prescription is written for fewer days). This is an addition to the above temporary supply.
If you have a change in level of care (for example discharged from the hospital to your home), we will cover a temporary 31-day supply (unless you have a prescription written for fewer days). 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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and bought at an in-network pharmacy. The transition policy can’t be used to buy a non-Part D drug or an out of network drug unless you qualify for out of network access.