Transition Supply Policy

Under certain circumstances, we will provide a temporary supply of a Part D covered drug that is not on our Drug List (formulary) or has restrictions, such as needing a prior authorization. This temporary supply, called a transition fill, gives you time to talk with your provider about the change in coverage and decide what to do. 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.

New Members: For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover one temporary one-month (30-day) 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.

Continuing Members: During the first 90 days of the new plan contract year, for each of your drugs that has affected by a negative formulary change, such as being removed from our Drug List, we will cover one temporary one-month (30-day) 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 no longer pay for these drugs.

Long-Term Care Resident: If you’re a resident of a long-term care facility, we’ll allow you to refill a prescription until we have provided you with at least a 31-day supply.

All members (and their prescribing provider) who has received a transition fill, will be sent a letter explaining the reason for the transition fill and information about the process. This letter will be sent within three business days of the transition fill.

For members who have been enrolled in our plan for more than 90 days and reside in a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover one 31-day emergency supply of that drug while you pursue a prior authorization or formulary exception.

If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. During this period, you can discuss options with your provider or use the plan’s exception process if you wish to continue coverage of the drug after the temporary supply is finished.

Our transition policy will not cover drugs that Medicare Part D does not normally cover.

For More Information

For more detailed information about your eternalHeath prescription drug coverage, please review your Evidence of Coverage.

If you have questions about our transition policy or need help asking for a formulary exception, please contact Pharmacy Member Services at 1 (800) 891-6989, 24 hours a day, 7 days a week. TTY users call 711.

Page Last Updated On: October 17, 2022
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Tom Cunniffe

Director of Operations 

Tom Cunniffe comes to eternalHealth with over 20 years of healthcare operations’ experience, having held leadership positions in Call Center, Enrollment, Credentialing, UAT and Reimbursement teams. Tom has worked with Medicaid, Commercial and Medicare lines of business and has consistently built teams who are metrics driven with proven successful outcomes. Making sure our business strives for an efficient, best-in-class customer experience is at the center of Tom’s philosophy.

Tom has a bachelor’s degree from Fordham University and a master’s in business administration from University of Massachusetts at Amherst.

Tom Lawless

Chief Financial Officer

Tom Lawless has spent the past 20+ years building, sustaining, and growing new healthcare-related programs that balance fiscal responsibility & prudence with creativity & innovation, focusing on models of care that are novel, person-centered, and improve the social welfare of those who are served. He is very excited to continue doing so in his role as the Chief Financial Officer of eternalHealth.

Tom comes to eternalHealth from a not-for-profit, member-centric, health insurance cooperative. He helped the company continuously strive toward its dual goals of thriving financially, while keeping members at the very epicenter of its mission and service model. While there, Tom also spearheaded the creation of a brand new private, charitable foundation, which will be meaningfully giving back to those in need in the surrounding communities for years to come. Previously, Tom worked in the finance department of a successful hospice that provided high-quality care to persons experiencing their unique and poignant end-of-life journeys, assuring that the appropriate financing was always available. Tom’s career began as a civil servant in the Wisconsin Medicaid program, where he helped to create a program that expanded the institutional entitlement to care into home and community-based settings. Starting with only a blueprint in hand, the program now serves more than 57,000 frail elders and disabled adults and is considered a national model. Growing into a senior leadership role, Tom was a key architect of an innovative financing model, through which the public and private sectors successfully collaborated to better the lives of persons in great need.

Tom holds undergraduate and graduate degrees from the University of Chicago, with additional graduate work in economics completed at the University Wisconsin-Madison.

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