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
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.
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:
- Immunosuppressant (for prophylaxis of organ transplant rejection)
Transition fill notification occurs in two ways:
- 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.
- 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
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.