Zing Health 2023 General Transition Policy
As a new or continuing member in our plan you may be taking drugs that are not on our formulary or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases under our transition process. This could occur during the first 90 days you are a member of our plan (for new members), or, in certain cases for continuing members affected by a negative formulary change across plan years, during the first 90 days of the new plan contract year.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day transition supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care (LTC) facility, we will cover a temporary 31- day transition supply (unless your prescription is written for fewer days). We will cover more than one refill of these medications during the first 90 days you are a member of our plan.
If you are a resident of a LTC facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception (unless your prescription is written for fewer days).
If you have a change in your medications due to a change in treatment setting (i.e., a level of care change) and you need a drug that is not on our formulary, we will provide up to a 30-day supply of medication. A level of care change may include:
- Members who enter long-term care (LTC) facilities from hospitals
- Members who are discharged from a hospital to a home
- Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and revert to their Part D benefit
- Members who give up hospice status to revert to standard Medicare Part A and B benefits
- Members who end a LTC facility stay and return to the community
- Members who are discharged from psychiatric hospitals with drug regimens that are highly individualized
For more information
For more detailed information about your Zing Health prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about our transition policy or need help asking for a formulary exception, please contact Customer Service at 1-866-946-4458.