Part D Transition Process

There is an important protection for Medicare beneficiaries called the “transition process” which applies for the first 90 days you are in a Medicare Part D drug plan. During this period it generally allows a beneficiary to continue to receive any prescription drug they were taking (1) whether or not the drug is on their plan’s formulary, and (2) even if it is on the formulary, if it has restrictions due to prior authorization or step therapy. Under this process, a beneficiary new to a plan can always get up to a 30-day supply of a drug; this will give them time to seek an alternate drug with their prescriber, or get a formulary exception from their plan, or attempt to find another way to pay for their drug. However, this process does not apply to drugs not covered by Part D. (This list is on page 95 of Managing Your Medicare.)

In these cases, a plan must supply a beneficiary with up to a 30-day supply of their prescription, and it must also notify the beneficiary, within three business days and by first class mail, that it is only a “temporary fill.” (These are also sometimes called “transition supplies” or “emergency supplies.”) The plan must also make a reasonable attempt to notify the prescriber of this. If the prescription is for multiple fills of less than 30 days, for example, four 7-day fills, the plan still must refill it up to a 30 days supply. (Note that for beneficiaries in long term care the plan must fill up to a 93-day supply in 31 day increments.)

Note that you are not expected to ask for this process to occur; it is supposed to be automatic. For example, if during your first 90 days in a drug plan you go to the pharmacy to get a prescription filled, and it so happens that your drug is not on your plan’s formulary, you plan is supposed to fill your prescription (up to a 30-day supply) without any intervention on your part. And that is why the notification part of this process is so important – you otherwise would probably assume that your drug is always going to be covered – and so it is critical that your plan notify you (and your prescriber) that this is NOT the case. However, if for some reason they do not automatically fill your prescrition, you can always call them and ask for a transitional fill.

And this process applies at other times than when you change or join a plan on January 1. The transition process applies to any beneficiary who joins a Part D plan whether or not they were previously in a plan (for example, they may change plans in the middle of a year because they changed residence; or perhaps they involuntarily lost their creditable drug coverage and they now first join a plan).

And, importantly, it applies to those who are in a plan when the plan changes its formulary so their drug is no longer covered by their plan, or when their plan now imposes prior authorization or step therapy on their drug. Because formulary changes often take place on January 1 of a calendar year, beneficiaries who stay in the same plan are also covered by this process when the formulary changes at that time. And in these cases where the formulary changes, the-90 day window starts when the formulary changes.

So be sure to act promptly if you get a notice that your drug is not ordinarily covered, or that your plan will begin prior authorization or step therapy.

And remember, you always have your appeal rights to try to get your plan to cover a drug you need. You are certainly free to use them when you find out your drug is not on the formulary or will be subject to prior authorization or step therapy. The notice you get from your plan will tell you how to make an exception request and of your appeal rights; all these Part D appeals rights are also fully spelled out beginning on page 206 of Managing Your Medicare.

Change of Care Transitions

Note that there is another transition which Centers for Medicare & Medicaid Services has instructions on. This is called a “change of care transition.” This is when a beneficiary who is enrolled in Part D goes from one institution to another (especially from one that provides all their medicines, such as an inpatient hospital or Skilled Nursing Facility) to one that does not, such as a long term care facility), or from an institution to home, or even beneficiaries who opt to end their hospice care and go back to regular care. (Hospices supply some medications under the Part A benefit, but a when a beneficiary is discharged from a hospice, not only will the beneficiary become responsible for their medications, but their medications may well change on discharge.) In these cases the Centers for Medicare & Medicaid Services has asked that drug plans consider using the transition process, but they are not required to do so. So you can at least review your plan’s literature to see what their policy is, or ask them. And if they do not have a transition policy for these cases, you will have to use the expedited appeals process to try to get a medicine that is not on your plan’s formulary or which requires prior authorization or step therapy.