Prescription Drug Transition Policy

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New members in Brandman Health Plan may be taking drugs that aren't in our Drug List (Formulary) or that are subject to certain restrictions, such as prior authorization, step therapy, or that have an approved quantity limits lower than the member's current dose. Current members may also be affected by changes in our formulary from one year to the next.

In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

To get a temporary supply of a drug, you must meet the two criteria below:

  1. 1 The drug you have been taking:
    • is not listed on our Drug List or
    • no longer on our Drug List, or
    • is listed but now limited in some way (For example, prior authorization or step therapy)
  2. 2 You must be in one of these situations:
    • You are new to our plan
    • You were in the plan last year
    • You are living in a long-term care facility

We will cover a ​temporary supply of your drug during the first 90 days of the calendar year. If you have been in the plan for more than 90 days and live in a long-term facility and need a supply right away, we will cover to up to an approved month’s supply, or less if your prescription is written for fewer days. This is in addition to the above temporary supply. Exceptions are available to you if you experience a change in the level of care you receive or need to transition from one facility to another.

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. If we cover another drug for your condition, we strongly encourage you to ask your doctor if any of these drugs is an option for you. If your doctor tells you that none of the drugs we cover for treating your condition is medically appropriate for treating your condition, you have the right to request a formulary exception from us. You also have the right to request a formulary exception if your doctor tells you that a prior authorization, quantity limit, or other limit we have placed on a drug you are taking is not medically appropriate for treating your condition.

If you need help asking for an exception, you can contact us at 1-844-374-7377, 24 hours a day, 7 days a week.

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