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First Fill Information

Transition Policy and Exceptions

1. What If My Drug Is Not On The Formulary?
2. First Health Part D (PDP)'s Transition Policy – New members
3. First Health Part D (PDP)'s Transition Policy – Existing members
4. How Can I Request An Exception To First Health Part D (PDP)'s Formulary?
5. First Health Part D (PDP)'s Process for Filing an Exception
6. First Health Part D (PDP)'s Step Therapy and Prior Authorization Process

1. What If My Drug Is Not On The Formulary?
If your prescription is not listed on our formulary, you should first contact Customer Service to be sure it is not covered. You can contact Customer Service.

If Customer Service confirms that we do not cover your drug, you have three options:
  • First Health Part D (PDP) can help you identify similar drugs on our formulary that are used to treat the same medical condition
  • You can ask us to make an exception and cover your drug. See “How Do I Request An Exception”?
  • You can pay out-of-pocket for the drug and request that the plan reimburse you. Unless it is an emergency, if you did not follow our exception process or the exception was not approved, your request for reimbursement may be denied. If First Health Part D (PDP) denies your request for reimbursement, you have the right to file an appeal.
If you recently joined First Health Part D (PDP) and learn that we do not cover a drug you were taking when you joined our plan, you may be able to receive a one-time fill of that prescription. You can receive a one-time fill of the non-covered drug if one of the following applies:
  • You didn’t know that your drug wasn’t covered by First Health Part D (PDP), or
  • You knew it wasn’t covered but you didn’t know that you could request an exception to First Health Part D (PDP)’s formulary.
  • After your one-time fill, First Health Part D (PDP) can help you identify similar drugs on our formulary that are used to treat the same medical condition. If we cannot find another drug for you, we will help you file a request for an exception to our formulary.
  • In some cases, First Health Part D (PDP) will contact you if you are taking a drug that is not on our formulary. We will let you know that your drug is not covered and help you identify similar drugs on our formulary that are used to treat the same medical condition.
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2. First Health Part D (PDP)’s Transition Policy for New Members
  1. If the your medication is currently covered on one of the formulary copay tiers, then there is no action needed.


  2. Quantity Limitations: For certain drugs, First Health Part D (PDP) limits the amount of the drug that we will cover per prescription or for a defined period of time. For example, First Health Part D (PDP) will provide up to 4 units per prescription for FOSAMAX 70mg per 30 days. If the medication is listed on the Quantity Level Limitations (QLL) Lists, then there is no action needed.
    • Medications on the QLL are identified as once daily drugs (i.e. Zocor 20mg) or
    • Medications commercially packaged (i.e. inhalers, tubes, patches) or
    • Medications package insert states specific dosing (i.e. Fosamax Weekly)


  3. In some cases, First Health Part D (PDP) requires you to get Prior Authorization for certain drugs. This means that you will need to get approval from First Health Part D (PDP) before you fill your prescription. If you don’t get approval, First Health Part D (PDP) may not cover the drug. In other cases, First Health Part D (PDP) may require you to first try one drug to treat your medical condition before we will cover another drug for that condition. This is called Step Therapy. For example, if Drug A and Drug B both treat your medical condition, First Health Part D (PDP) may require your doctor to prescribe Drug A first. If Drug A does not work for you, First Health Part D (PDP) will then cover Drug B. For those medications listed on the Prior Authorization (PA) and Stepped Therapy (ST) Lists, the pharmacy system will allow a “first fill” without action needed by your prescriber.
    • The dispensing pharmacist may enter an override during your first 90 days of coverage with a plan to allow you to receive multiple fills of up to a 31-day supply of the prior authorized, step therapy or non-formulary medication. These temporary fills will allow you sufficient time to contact your prescribing physician (prescriber) so that the prescriber may request approval if treatment is necessary beyond the initial 90-day period.
    • We will send you a written notification of the “first fill” via U.S. mail to you as a reminder that the supply allowed is temporary and further action is needed to continue to receive the medication..
    • After the 30 day first fill, you and your prescribing physician will be required to follow the normal process for requesting prior authorizations and medical necessity review, step therapy, or exception processing.
    • Decisions on transitions will appropriately address situations involving your need to be stabilized on drugs that are not on our Plan’s formulary and have known risks associated with any changes in the prescribed regimen.


  4. Long Term Care (LTC) enrollees/residents will also receive a temporary supply of medication during their first 90 days of eligibility with a plan. However, due to the unique nature of the LTC setting and the complex nature of this patient population, these beneficiaries are allowed multiple transition fills in quantities of up to 31-day supplies at a time. If you are a LTC beneficiary, you will qualify for temporary fills for the entire 90-day transition period.
    • The dispensing pharmacist may enter an override during your first 90 days of coverage with a plan to allow you to receive multiple fills of up to a 31-day supply of the prior authorized, step therapy or non-formulary medication. These temporary fills will allow you sufficient time to contact your prescribing physician (prescriber) so that the prescriber may request approval if treatment is necessary beyond the initial 90-day period.
    • We will send you a written notification of the “first fill” via U.S. mail to you as a reminder that the supply allowed is temporary and further action is needed to continue to receive the medication.
    • After the 90-day new member transition period, you and your prescribing physician will be required to follow the normal process for requesting prior authorizations and medical necessity review, step therapy, or exception processing.
    • Decisions on transitions will appropriately address situations involving your need to be stabilized on drugs that are not on the Plan’s formulary and have known risks associated with any changes in the prescribed regimen.
    • An emergency supply of medication for Long Term Care residents will be covered as follows: An emergency supply of up to a 31-day supply will be allowed any time after the initial 90-day new member transition period as long as it a medication that is new to the patient.
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3. Transition for Existing Members:
This applies to currently enrolled members past the initial transition period of 90-days (see process outlined above)

  1. Annual changes to the tiers of medication.
    • Should a medication the enrollee is currently taking be removed from the formulary for the next benefit year, the enrollee will receive written notification informing them of the changes taking place in their annual notice of change (ANOC) document. Members will receive this documentation (60) days prior to the effective date of the next plan benefit year. During this 60-day period, the enrollee will be able to obtain the original medication at the pre-existing copay tier. This advance notice will allow time for the beneficiaries/prescribers to make an exception request or change to a formulary medication.


  2. Non-annual changes to medications may occur.
    • If a medication is removed from the market, you will be notified, along with the therapeutically equivalent substitution on the same tier, if applicable.
    • If a Part D medication currently covered, receives a new FDA indication, the P&T Committee will review the clinical information related to new indication and may change and/or require prior authorization and/or stepped therapy.
    • If a Part D medication is deemed to be unsafe.
    • The enrollee will be notified of these non-annual changes as soon as possible. Depending on the change, a 60-day period of transition may not be possible or appropriate. The notice to the you and your physician will describe the specific transition process.

  3. Level of care changes
    • Unplanned transitions for current enrollees could arise where prescribed drugs are not on the Plan’s formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For example, enrollees who enter LTC facilities from hospitals or from a hospital discharged home. For these unplanned transitions, enrollees and providers need to utilize the Plan’s exception and appeals process should the drugs not be on the Plan’s formulary. LTC beneficiaries will be allowed a one time emergency supply of up to a 31 day supply for medications which the beneficiary has not already received a transition supply. In addition, The dispensing pharmacist will be able to override early refill edits, where appropriate, for members entering or being discharged from a LTC facility where beneficiaries are not allowed to take their previously filled medications with them to their new location.
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4. How Can I Request An Exception To First Health Part D (PDP)’s Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask First Health Part D (PDP) to make.
  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, First Health Part D (PDP) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Tier 3 drug, you can ask us to cover it as a Tier 2 drug instead. This would lower the co-payment you must pay for your drug.
Generally, First Health Part D (PDP) will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

In most circumstances, if we do approve your request for an exception, the exception is good for the rest of the year or the length of treatment approved.

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5. First Health Part D (PDP)’s Process for Filing an Exception
To request an exception, your prescribing physician may call toll-free at (800) 551-2694 (TDD 1-800-236-1069)or fax the request to (800) 639-9158. First Health Part D (PDP)’s hours of operation are 9:00 am to 9:00 pm (EST), Monday through Friday.

After hours your physician may call First Health Part D (PDP) at (800) 551-2694 (TDD 1-800-236-1069). First Health Part D (PDP) will notify your physician that if this is an emergency. Your prescribing physician may then call the clinical call center once it re-opens to request a long term exception.

If your physician requires an immediate response, the Customer Service representative will contact the First Health Part D (PDP) on-call pharmacist who will respond to the prescriber as quickly as possible.

To request an exception, your prescribing physicians needs to provide the following information:
  • Your full name (First name and Last name)
  • Your First Health Part D (PDP) Member ID number located on your ID card
  • Requested drug
  • Reason for the exception
Once an exception request is approved, it is valid for the remainder of the plan year or the length of therapy authorized so long as your physician continues to prescribe the drug for you and it continues to be safe and effective for treating your condition.

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6. First Health Part D’s Step Therapy and Prior Authorization Process
To request prior authorization or to place you in step therapy, prescribing physicians follow the exception process described below.
  1. Call 800-551-2694 (TDD 1-800-236-1069) or fax the request to (800) 639-9158 between 9:00 am - 9:00 pm eastern time, Monday through Friday.
    • Provide the following information:
    • Your full name (First name and Last name)
    • Your First Health Part D (PDP) Member ID number located on your ID card
    • Requested drug
    • Reason for the request
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Page Last Updated Not Available
CMS Approved 1/15/2010
CMS Document ID CMS Document ID: M0003C0002_09MAPDPDP_502_CVTYWEBf