Transition Process


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).
  • 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. Under certain circumstances, the plan can offer a temporary supply 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. Perhaps there is a different drug covered by the plan that might work just as well for you.

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 the plan’s Drug List.
    • -- or -- the drug you have been taking is now restricted in some way
  2. You must be in one of the situations described below:
    • For those members who were on 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-day supply, 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 the calendar year. This temporary supply will be for a maximum of 30-day supply, 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 93 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills, up to a 93 day supply 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 31day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

New members on our Plan may be taking drugs that are not on our formulary or that are subject to certain restriction, such as prior authorization or step therapy. Current members may also be affected by changes to our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception. Please contact PrimeTime Health Plan at 1-800-577-5084 or, for TTY users, 1-800-617-7446, Monday through Friday, 8:00 a.m. to 8:00 p.m. (October 1st – February 14th, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.).

If you and your doctor or other prescriber want to ask for an exception, please refer to your Evidence of Coverage. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

To view PrimeTime Health Plan’s Transition Policy and Procedure, click here.

Last updated: 10/1/2015