Drug Transition Process Content

Medicare Icon Drug Transition Process

HealthPlus of Michigan Medicare Part D (HealthPlus MedicarePlus) transition process includes a written description of how enrollees whose current drug therapies may not be included in the MedicarePlus formulary may receive a temporary supply of a non-formulary drug, as well as Part D drugs that are on the formulary but require prior authorization or step therapy under the MedicarePlus utilization management rules.

A meaningful transition period allows sufficient time for members to work with their health care provider to select an appropriate formulary alternative or to request a formulary exception based on medical necessity.

The Transition Policy applies to the following enrollees:

  • New enrollees into prescription drug plans at the beginning of a contract year
  • The transition of newly eligible Medicare beneficiaries from other coverage at the beginning of a contract year
  • The transition of individuals who switch from one plan to another after the beginning of a contract year
  • Enrollees residing in long-term care (LTC) facilities
  • Current enrollees affected by formulary changes from one contract year to the next

Transition Fills in the Outpatient (Retail) Setting

The outpatient pharmacy setting includes retail, mail order, home infusion, and I/T/U pharmacies. A one-time, temporary, 30-day supply (unless the prescription is written for less than a 30-day supply) of non-formulary drugs will be provided anytime during the 90-day transition period.

Transition Fills in the Long Term Care (LTC) Setting

Multiple fills of a temporary, 31-day supply (unless the prescription is written for less than a 31-day supply) will be provided during the 90 day transition period. MedicarePlus honors multiple fills of non-formulary Part D drugs during the entire length of the 90-day transition period, for up to a 98-day supply.

Emergency Supplies and Level of Care Changes

An emergency transition supply is defined by CMS as a one-time fill of a non-formulary drug that is necessary with respect to current members in the LTC setting, and will be provided to current long-term care enrollees who enter into a facility from another care setting. MedicarePlus has authorized our Claims Processor to place a manual override at the point of sale to accommodate a one time (up to 31 days) fill in this scenario.

Transition Across Contract Years

CMS transition guidance requires that current members affected by a negative formulary change across contract years are provided with a transition process that is consistent with the transition process required for new enrollees. Logic is in place at the Point of Sale to accommodate this by allowing current members to access transition supplies when their claims history from the previous calendar year contains an approved claim for the same drug that the member is attempting to fill through transition.

Transition Extension

MedicarePlus acknowledges that situations may exist in which the member’s transition period may need to be extended, on a case-by-case basis, such as when the member’s exception request or appeal has not been processed by the end of the minimum transition period and until such time as a transition has been made. In these situations, MedicarePlus may extend the member’s transition period in order to provide continued coverage of the transition drug(s).

Cost Sharing for Transition Supplies

For low-income subsidy (LIS) eligible members, the cost-sharing amount applied during claims adjudication does not exceed the statutory maximum copayment amounts. For non-LIS members filling non-formulary drugs, the cost-sharing amount applied during claims adjudication will be consistent with the Plan’s approved drug cost-sharing tiers for non-formulary drugs approved under the Plan’s exception process. Additionally, for non-LIS members filling formulary drugs with UM requirements, the cost-sharing amount applied during claims adjudication is the cost associated with the Plan’s assigned formulary tier.

Six Classes of Clinical Concern

Per CMS guidance, members transitioning to a Plan while taking a drug within the six classes of clinical concern must be granted continued coverage of therapy for the duration of treatment, up to the full duration of active enrollment in the Plan. Utilization management restrictions and/or non-formulary status, which may apply to new members naïve to therapy, are not applied to those members transitioning to the Medicare Part D plan on agents within these key categories. The six classes include:

  • Antidepressant
  • Antipsychotic
  • Anticonvulsant
  • Antineoplastic
  • Antiretroviral
  • Immunosuppressant (for prophylaxis of organ transplant rejection)

Member Notification

Transition fill notification occurs in two ways:

  1. Point-of-sale notification goes to the pharmacy at time of adjudication with messaging that may be passed to the member regarding the status of the particular non-formulary drug or drug with UM. The transition messaging goes to pharmacies in a retail setting (including home infusion, mail order, and I/T/U) as well as pharmacies in an LTC setting.
  2. MedicarePlus will send written notice via U.S. first class mail to enrollee within three business days of adjudication of a temporary fill. The notice will include:
    • an explanation of the temporary nature of the transition supply an enrollee has received
    • instructions for working with the plan sponsor and the enrollee's prescriber to identify appropriate therapeutic alternatives that are on the plan's formulary
    • an explanation of the enrollee's right to request a formulary exception
    • a description of the procedures for requesting a formulary exception

Exception Plan

Formulary exception request forms are available to members, their appointed representatives and physicians by mail, fax and email.

For More Information

See Chapter 5 of your Evidence of Coverage to learn more about the MedicarePlus Transition Process. You can find the Evidence of Coverage for your specific plan in the MedicarePlus Resource Library.