There are some circumstances under which the plan can offer a temporary supply of a drug if the drug is not on the Drug List (Formulary) or if it is subject to certain clinical criteria. This gives you time to talk to your doctor about your drug therapy.
If the drug that you have been taking is no longer on your plan’s Drug List or if it now has some preauthorization or step therapy criteria, you can be eligible to obtain a temporary supply.
To be eligible you should be in one of the situations described below:
We will cover a temporary supply of your drug during the first 90 days under your plan in the coverage year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.
We will cover a temporary supply of your drug one time only during the first 90 days of your membership to the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.
If the member is a resident in a long-term care facility, the plan will provide a supply up to 98 days during this period, in accordance with the dispatch increase, with necessary refills (unless the prescription indicates less refills).
We will cover one 30-day supply of drugs that are not included on the Drug List or have any restrictions.
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. You and your doctor could also ask the plan to make an exception for your case and cover the drug in the way you would like it to be covered. The sections below inform you more about these options.
Start by talking to your doctor. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor identify a covered drug that might work for you.
You and your doctor or other prescriber, can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule. For example, you can ask the plan to cover a drug even if it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.
For more detailed information, see Chapter 9, under section "What is an exception?" of your plan's Evidence of Coverage or call Member Services.
See here our Medication Transition Policy:
Medicare y Mucho Más (MMM) (HMO), PMC Medicare Choice (PMC) (HMO) and FIRST+PLUS (PPO), products offered by MMM Healthcare, LLC, are plans with a Medicare contract. Enrollment in the plans depends on contract renewal. To enroll, you must have Medicare Parts A and B, have not been diagnosed with End Stage Renal Disease (ESRD) and reside within the 78 municipalities of the Island. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. MMM Healthcare, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-333-5470. (TTY: 1-866-333-5469). Lunes a domingo, de 8:00 a.m. a 8:00 p.m.
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