Getting a "transition fill" refill
Qualify for a one-time supply of a drug your plan doesn't cover
If you join a Priority Health plan and are taking a drug that your plan lists as "not covered" (see below for a definition), you may qualify for a one-time refill, known as a "transition fill" or "temporary supply."
How to get a temporary supply
- Your pharmacist will enter your prescription and get a code that lets him/her order it as a transition fill.
- Your pharmacist will give you a one-time supply for up to 31 days of your drug. You will pay a copay.
- You then have 30 days to work with your doctor to switch to a drug covered by your plan or to ask for a "formulary exception," meaning asking Priority Health to pay for your drug. See "Asking for an exception," below.
Time limits for requesting a temporary supply
You have 120 days from the date your insurance begins to apply for a transition fill.
Some drugs and some quantities are not eligible
For example, Priority Health will not pay for a temporary supply if:
- Your drug is listed as "excluded" or "not covered" by Priority Health (see below)
- Your prescription is written for a higher dose than we normally allow
- Your prescription is written for a larger supply than we normally allow
- You go to a pharmacy that is not in your plan's pharmacy network
Asking for an exception
If you think your Priority Health plan should pay for your drug even though it is listed as "not covered" or "excluded," or if you think you should not have to meet the special requirements for step therapy (trying other drugs first) or prior authorization by Priority Health, you can request a "formulary exception."
If your drug is listed as "excluded" on your plan's Approved Drug List, it is never covered by any Priority Health plan and a transition fill is not allowed. Weight-loss drugs are listed as "excluded," for example.
If your drug is listed as "not covered" on your plan's Approved Drug List, it means:
- You and your doctor need to either find a substitute drug that is covered, or ask for an exception (step 3 above under "How to get a temporary supply").
- Priority Health requires you to try other drugs first ("step therapy") before we will pay for it. Again, you can ask for an exception (see above).
- You have to get approval up front from Priority health ("prior authorization") before Priority Health will pay for it.