Getting a transition fill
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."
Priority Health Medicare members
The rules about transition fills are a little different under Medicare.
See details on how Priority Health Medicare plans handle transition fills.
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
From the start date of your plan (the "effective date"):
- Priority Health Medicare plan members have 90 days to apply for a transition fill. You may be able to arrange for an extension/additional transition fills if you meet certain conditions.
- All other Priority Health plan members have 120 days 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 medication is listed as "excluded" by Priority Health (see below)
- Your prescription exceeds our maximum dosage or quantity limits
- You go to a pharmacy that is not in your plan's pharmacy network
- It is listed as "not covered" or "excluded from coverage" under Medicare Part D*.
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."
"Not covered" vs. "excluded"
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:
- It is not on the Approved Drug List for your plan, so you and your doctor need to either find a substitute drug that is on the list or ask for an exception (step 3 above under "How to get a temporary supply").
- It is on the list but Priority Health requires you to try other drugs first ("step therapy") before we will pay for it. Again, you can ask for an exception (step 3 above under "How to get a transition refill").
- It is on the list but you have to get approval up front from Priority health ("prior authorization") before Priority Health will pay for it.
Learn more about using the Approved Drug List
Check out our FAQs.
