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Prescription Drug Transition Process

What to do if your current prescription drugs are not on the Drug List (formulary) or are restricted in some way

New members

As a new plan member, you may currently be taking drugs that are not on the plan’s formulary (drug list), or they are on the formulary but are restricted in some way.

In instances like these, start by talking with your doctor about appropriate alternative medications available on the formulary. If no appropriate alternatives can be found, you or your doctor can request a formulary exception. If the exception is approved, you may be able to obtain the drug for a specified period of time. While you and your doctor are determining your course of action, you may be eligible to receive a transition supply of at least a 1-month supply as described in your plan’s Evidence of Coverage of most drugs anytime during the first 90 days of membership in the plan. If the prescription is written for fewer days, multiple fills are allowed during the first 90 days until you’ve received at least a 1-month supply of your drug as described in your plan’s Evidence of Coverage. After your transition supply, these drugs may not continue to be covered.

If you live in a long-term care facility, but you are past the first 90 days of membership in our plan, the transition program may cover at least a 31-day emergency supply of most drugs while you pursue a formulary exception.

You may face unplanned transitions after the first 90 days of plan enrollment, such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care). For many drugs that are not on our Drug List or your ability to get your drugs is limited in some way, you are required to use the plan’s exception process. You can request a one-time temporary supply of at least a 1-month supply, as described in your plan’s Evidence of Coverage, to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

Continuing members

As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). You may notice that a drug you are currently taking is either not on the upcoming year’s formulary or is on the formulary but restricted in some way in the upcoming year.

Starting October 15, 2021, you may request a 2022 coverage review. If your request is approved, the plan will cover the drug as of January 1, 2022.

If your drug is subject to new formulary restrictions on January 1, 2022 and you have not discussed switching to an alternative formulary medication or pursued a formulary exception with your doctor, you may receive a temporary supply within the first 90 days of the new calendar year when you go to a network pharmacy. This would be at least a 1-month supply, as described in your plan’s Evidence of Coverage, to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you live in a long-term care facility, you can obtain multiple refills until you’ve reached at least a 31-day supply, including when prescriptions are dispensed for less than the written amount due to drug utilization edits that are based on approved product labeling.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Part D coverage or when taken off hospice care) that can occur anytime. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is restricted in some way, you are required to use the plan's exception process. For most drugs, you may request a one-time temporary supply of at least one month, as described in your plan’s Evidence of Coverage, to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility and need an emergency supply, we will cover at least a 31-day temporary supply.

If you have any questions about this transition policy or need help asking for a formulary exception, contact a member services repreesntative.

For prescription drug transition process information in Spanish, go to Forms and Resources and view section 5.2 of your Evidence of Coverage (Spanish) for more information.

Related Information

The Coverage Determination Request Form may be found under Appeal a Coverage Decision section on this page.

Medication Therapy Management Program

UnitedHealthcare’s Medication Therapy Management (MTM) program was developed by a team of pharmacists and doctors. The MTM program provides members with a comprehensive medication review (CMR) with a pharmacist or other qualified health care provider. The program helps members understand their drug coverage and how to use their medications, and also educates members of potentially harmful drug interactions and/or risks of side effects.

How to Qualify
What You Need to Do
What's Next

How to Qualify
This program is available at no additional cost. You’ll be automatically enrolled in the Medication Therapy Management program if you:

• take eight (8) or more chronic Part D medications, and
• have three (3) or more long-term health conditions from the following list:
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Heart Failure
  • High Cholesterol
  • Osteoporosis
• and are likely to spend more than $4,696 a year on covered Part D medications

OR

• are in a Drug Management Program to help better manage and safely use medications such as those for pain. 

What You Need to Do
Within 60 days of becoming eligible for the MTM program, you’ll receive an offer by mail to complete a Comprehensive Medication Review (CMR). You may also receive this offer by phone.

You can complete the CMR by phone or in person with a qualified health care provider. It takes about 30 minutes. A pharmacist, or qualified CMR provider, will review your medication history, including prescription and over-the-counter medications, and look for any issues.

What's Next
Within 14 days of the CMR, you’ll receive a packet containing a summary of the review including action items discussed and a list of the medications you are taking and why you take them. This can be helpful when meeting with your doctor or pharmacist. The results may be sent to your doctor. In addition, members in the MTM program will receive information on the safe disposal of prescription medications including controlled substances.  

You can also download a blank Medication List (PDF) for your own personal use.

In addition to the CMR, Targeted Medication Reviews are done at least quarterly. This is done to find any drug-drug interactions or other medication concerns. Those reviews will be sent to your doctor.

The Medication Therapy Management program isn’t a plan benefit.  For more information on UnitedHealthcare’s Medication Therapy Management program, please call the number on the back of your plan member ID card or you may call the OptumRx MTM clinical call center team at 1-866-216-0198, TTY 711, Monday – Friday 9AM – 9PM EST.

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You may also go to OptumRx to order and manage your prescription drugs online.