- Service Area
- Benefits
- Formulary
- Grievances & Appeals
- Pharmacy Network
- Pharmacy Directory
- QA Policies & Procedures
- Appointing a Representative
- Plan Transition
- Disenrollment Rights
Plan Transition
Transition Policy
New SWH members may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 of the Evidence Of Coverage booklet under "What is an exception?" to learn more about how to request an exception. Please contact Member Services 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.
During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in SWH. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug. If you need a refill for the drug during the first 90 days of the new plan year, SWH 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 supply (unless the prescription is written for fewer days). 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. In many cases, where it is clinically appropriate, we may approve the continuation of an important drug that you have been stabilized on. In those situations, you will receive an approval letter.
If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in SWH (when the member is a resident of a long-term care facility). If a new member who is a resident of a long-term-care facility has been enrolled in SWH for more than 90 days and needs a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.
SWH and its pharmacy vendor will use multiple approaches to ease the transition of new enrollees who may be on drugs that are not part of the SWH drug benefit or have other restrictions associated with them. This policy specifically applies to non-formulary drugs, drugs requiring step therapy, prior authorization or other rules that would limit the immediate access of continuation of an existing drug therapy by a new enrollee.
A temporary 30-day fill will automatically be processed at retail within the first 90 days of a beneficiary's enrollment. In a long term care setting, medications can be filled and refilled up to 90 days following an enrollment.
Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Section 10 Evidence Of Coverage booklet for information about non-Part D drugs.
Non-Formulary Prior Authorization Request Form is available for download on the Grievances & Appeals page.
Last modified: 06/21/2010