Common Questions Regarding Drug Coverage

What can Peoples Health patients do if their drug is no longer on the Peoples Health formulary or if the drug is restricted in some way?

  • Get a temporary supply of the drug (only those in certain situations can get a temporary supply); this will give you time to talk with the patient about their drugs, to transition the patient to another drug, or to request an exception
    • Eligibility for a temporary drug supply is determined by either of the following:
          • The drug is no longer on the formulary
          • The drug is now restricted in some way
        • Change to another drug
        • Request an exception using the Request for Medicare Prescription Drug Coverage Determination Form and ask the plan to cover the drug or remove restrictions from the drug

What if a patient, including those in a long-term care facility, needs a transition supply of a drug?

For new and current plan members who aren’t in a long-term care facility, we will cover a temporary supply of a drug during the first 90 days of enrollment in the plan and during the first 90 days of the calendar year if they were in the plan last year. The temporary supply will be for at least a 30-day supply. If the prescription is written for fewer days, we allow multiple fills to provide up to a maximum of a 30-day supply. The prescription must be filled at a network pharmacy. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

For those who are a resident of a long-term care facility, we will cover a temporary supply of a drug during the first 90 days of enrollment in the plan and during the first 90 days of the calendar year if they were in the plan last year. The total supply will be for a maximum of a 31-day supply.

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 at least a 31-day emergency supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the long-term care transition supply available when they join a Peoples Health plan. 

In addition, we provide a transition process for Peoples Health patients who experience a level-of-care change and are currently on a medication regimen that contains non-formulary drugs or formulary drugs with restrictions. This transition process will occur when the coverage determination processing time frames are in conflict with the prescribed drug regimen. For patients who aren’t in a long-term care facility, we will cover up to a 30-day temporary supply of these non-formulary drugs or formulary drugs with restrictions. For patients in a long-term care facility, we will cover up to a 31-day temporary supply of these non-formulary drugs or formulary drugs with restrictions. Level-of-care changes include discharges from hospitals or psychiatric facilities, admissions to or discharges from long-term care facilities, giving up hospice status, or exceeding the limit for days covered during a skilled nursing facility stay. 

How does a patient request an exception to the Peoples Health formulary?

A patient or the patient’s physician or other prescriber can ask us to make an exception to our coverage rules. There are several types of exceptions that can be requested:

      • To cover a drug even if it is not on our formulary.
      • To waive coverage restrictions or limits on a drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If a drug has a quantity limit, you or your patient can ask us to waive the limit and cover more.
      • To provide a higher level of coverage for a drug.
        • If a drug is on our generic tier (tier 2), you or your patient can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred generic tier (tier 1) instead.
        • If a drug is on our nonpreferred brand tier (tier 4), you or your patient can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred brand tier (tier 3) instead.

This would lower the amount the patient must pay for the drug. Please note, if we grant a request to cover a drug that is not on our formulary, a patient may not ask us to provide a higher level of coverage for the drug. Also, patients may not ask us to provide a higher level of coverage for drugs in the preferred generic tier (tier 1), preferred brand tier (tier 3) or specialty tier (tier 5).

Generally, we will only approve a request for an exception if the additional utilization restrictions would not be as effective in treating the condition or would cause adverse medical effects.

An exception is a type of coverage decision. When patients request an exception, a statement from their physician supporting the request must also be submitted. Generally, Peoples Health must make a decision within 72 hours of receiving a prescribing physician’s supporting statement. An expedited (fast) coverage decision can be requested if the provider believes that the patient’s health could be seriously harmed by waiting up to 72 hours for a decision and the patient has not already purchased the drug. If the request to expedite is granted, we must give a decision no later than 24 hours after we receive the prescribing physician’s supporting statement. 

Providers with questions about pharmacy limitations, restrictions or exceptions for noncovered drugs may contact OptumRx at 1-800-711-4555, Monday through Friday, from 7 a.m. to 12 a.m. CST, or on Saturday, from 8 a.m. to 5 p.m. CST. Requests may also be faxed to 1-844-403-1028.