Prescription Drug Transition Policy
As a new or continuing member in our plan, you may be taking drugs that aren't included on our formulary or drugs that are included but aren't as easily accessible as they used to be. For example, you may need a prior authorization from Clover Health before filling your prescription. In certain cases, Clover Health may provide a temporary supply of a drug.
For new members who aren’t residents in a long-term care facility: Clover Health will cover a temporary one-time-only supply of your drug during the first 90 days of your membership in the plan. At maximum, this will be a temporary 30-day supply and may be less if your prescription is written for fewer days.
For new members who are residents in a long-term care facility:We'll cover a temporary supply of your drug during the first 90 days of your membership in the plan. At maximum, this will be a 31-day supply, and may be less if your prescription is written for fewer days.
As a continuing member in our plan, you'll receive an Annual Notice of Change (ANOC) each year. This document includes information on changes to plan costs and benefits for the next benefit year. It also refers you to the Clover Health Formulary or “Drug List” to review whether a formulary medication you're currently taking is either not on the upcoming year's formulary, or its cost sharing or coverage is limited in the upcoming year.
For continuing members who aren’t residents in a long-term care facility: If your existing medication is subject to new formulary restrictions and you haven’t yet pursued an alternative medication under your doctor's guidance, you’ve got options. Until you get a chance to discuss these alternatives with your doctor, you may visit a network pharmacy and receive a temporary 30-day supply of your current medication—unless the prescription is written for less than 30 days.
For continuing members who are residents in a long-term care facility: If your existing medication is subject to new formulary restrictions, we'll cover up to one temporary 31-day supply—unless you have a prescription written for less than 31 days.
While receiving a temporary supply of a drug, talk with your doctor to decide what to do when that supply runs out. Perhaps there's an alternative drug covered by the plan that works just as well for you. Or you and your doctor can ask Clover Health to make an exception for you, covering the drug in the way you'd like it to be covered.
Additional information can be found in the 2022 Transition Fill Policy and 2023 Transition Fill Policy.
If you need further assistance with any formulary-related issue or simply have questions about drug coverage in general, please contact us toll-free at 1-888-778-1478 (TTY 711), 8am – 8pm local time, 7 days a week.*
Part D (Formulary and Pharmacy Network)
Part D Coverage Determinations, Exceptions, Grievances, and Appeals