California PHP

If your drug is not on our formulary (list of covered drugs), is restricted or removed from the formulary during the year, there are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your doctor time to change to another drug or to file an exception.
• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the formulary or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:
   • The drug you have been taking is no longer on our formulary.
   • The drug you have been taking is now restricted in some way. For example it may have quantity limits, require prior authorization from us, or require that you try another drug first.
2. You must be in one of the situations described below:
   • For those members who were in the plan last year and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
   • For those members who are new to the plan and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
   • For those who are new members, and are residents in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
   • For those who have been a member of the plan for more than 90 days, and are a resident of a long-term care facility and need a supply right away: We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

To ask for a temporary supply, contact Pharmacy Benefit Customer Service.

During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered.

For more information about the plan’s prescription drug transition policy, please contact Pharmacy Benefit Customer Service.