Senior Care Options (SCO) and One Care pharmacy benefits

Mass General Brigham Health Plan's Transition Policy exists to provide new (and some current) enrollees immediate access to prescription drugs within 90 days of enrollment for non-formulary drugs and drugs with utilization management requirements, such as the need for a prior authorization from us.

Who is eligible for a transitional supply?

A transitional supply, or transition fill, is available to members within 90 days of your enrollment effective date in the following circumstances:

• Join or switch drug plans during the annual Open Enrollment Period between Oct 15-Dec 7,
• Join or switch drug plans during the year using another type of enrollment period (e.g., Initial Enrollment Period, Special Enrollment Period, or Medicare Advantage Open Enrollment Period),
• New and current plan members who live in long-term care (LTC) facilities, and
• May be available to some current plan members who are negatively affected by formulary changes from one plan year to the next.

Does the transition policy apply to all drugs?

The transition policy does not apply to Part D excluded drugs, new prescriptions, or to drugs that have been removed from a plan’s formulary because of FDA safety recalls. The transition policy does apply to both non-formulary drugs and drugs with utilization management requirements.

What is utilization management?

Utilization management (UM) is a restriction or action required by your plan before we will pay for medication. Quantity limits, step therapy, or prior authorization are common utilization management restrictions. These restrictions often require a doctor or prescriber to submit information about your medical condition or treatment before we can pay for the medication, even though the drug is on the formulary.

What do I do next?

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.