Transitioning to and from our Medicare plan
New Members
As a new member in our plan, you may currently be taking drugs that are not on our formulary or taking drugs that are on our formulary in a limited basis. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary.
If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30-day transition supply of the drug anytime during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or for situations where 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) when you go to a network pharmacy. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (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 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.
Continuing Members
As a continuing member in the plan, you will receive your formulary (with a clickable link). You may notice that a formulary medication, which you are currently taking, is either not on the upcoming year’s formulary or its cost sharing or coverage is limited in the upcoming year.
In this case, you must work with your doctor to either find an appropriate alternative therapy on our new formulary or request a formulary exception prior to the beginning of the new year. If the exception request is approved, we will authorize payment.
For AZ Blue members that move from one level of care to another as described below, AZ Blue will provide a temporary, one-time up to 30-day supply of a Part D eligible non-formulary medication. This one-time, fill needs to be authorized through the exception process. Therefore, your doctor or pharmacist will need to call our contracted pharmacy benefit manager OptumRx at 1-844-883-8524, TTY: 711 and let them know that you are moving from one level of care to another.
Examples of moving (or transitioning) from one level of care to another include the following:
- Members transitioning from hospital to home (discharge medications)
- Members transitioning from a Skilled Nursing benefit (LTCF) and reverting to the Part D benefit
- Members terminating a Hospice election and reverting to Part A and Part D benefit
- Members discharged from a Chronic Psychiatric Hospital to home (discharge medications)
If you have any questions about our transition policy or need help asking for a formulary exception, call AZ Blue.
