Medication Transition Process

Click here to view Vitality Health Plan of California’s Prescription Drug Transition Policy.

What can you do if your drug is not on the Drug List or if the drug is restricted in some way?

If your drug is not on the Drug List or is restricted, here 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 (Transition fill) of a drug to you when your drug is not on the Drug List 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 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 (LTC ) facility: We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. 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 (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 31-day supply. If your prescription is written for fewer days, we allow multiple fills to provide up to a maximum of a 31-day supply of medication. The prescription must be filled at a network pharmacy.

For those members who were in the plan last year and reside in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The total supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

For those members who are new to the plan and reside in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The total supply will be for a maximum of 30-days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-days of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.).

For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away: We will cover one 30-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

For those members who have been in the plan for more than 90 days and have a level of care change: We will cover a temporary supply for up to 31 days, or less if your prescription is written for fewer days even if the drug is not on our formulary or the drug is subject to certain restrictions such as prior authorization or step therapy. The drug must be a Part D covered drug. The prescription must be filled at a network pharmacy.

We will send a letter after we cover a temporary supply of drugs.

We will provide with a written notice after we cover a temporary supply. This notice will explain the steps to request an exception and how to work with the provider to switch to an appropriate drug that we cover. After we cover the temporary 30-day supply, we may not pay for the drug again as part of our transition policy.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

Last updated 12/20/2018