If a member starts using a formulary protected class drug (PCD), how long must the plan cover it?

When a member begins using a formulary protected class drug (PCD), the plan is obligated to cover that drug for a minimum period of 30 days. This ensures that members can continue their treatment without interruption after starting a medication that is classified as a protected class drug. The intent behind this requirement is to provide stability and ongoing access to critical medications that may be essential for treating serious conditions. It supports patient adherence to their prescribed treatment and acknowledges the potential risks involved in abruptly discontinuing such medications.

The 30-day period is specifically designed to allow sufficient time for members to manage their treatment effectively, and while the coverage might extend beyond this timeframe based on specific conditions or regulations, the minimum guarantee is set at 30 days. Understanding this duration is crucial for both members and plans to navigate medication coverage and ensure appropriate treatment continuity.