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Drug Transition Policy

The transition program is for new and renewing members who are taking drugs that are not on the List of Drugs (Formulary) or are on the list of drugs, with a restriction (not based on safety). This includes both Part D and Medi-Cal drugs.

We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of our plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the list of drugs you can take instead or whether to request an exception.

We may cover a 30-day supply of your drug if:

  • you are taking a drug that is not on our list of drugs, or
  • health plan rules do not let you get the amount ordered by your prescriber, or
  • the drug requires prior approval by our plan, or
  • you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the first 90 days. This gives your prescriber time to change your drugs to those on the list of drugs or ask for an exception.

Emergency Supply

If you are in a nursing home or other long-term care facility and need a drug that is not on the list of drugs, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days). This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the list of drugs you can take instead or whether to request an exception.

Level of Care Changes

If your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.

  • If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply.
  • If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply.

Transition Letter

We will send you a transition letter when we cover a transition supply of your drug. You can ask for the transition letter in another format or language. To ask for the letter in another format or language, please contact Member Services.


Information last updated: 07/11/2018
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