Medicare requires all Part D Drug Plans to establish transition policies. These policies help you when you transition from one policy to another, or at the beginning of the year when formularies change.
When do you have transition rights?
You have transition rights under the following circumstances.
- When you first enroll in a Part D drug plan
- When you move to a new plan that does not cover your current drug, even if that move happens in the middle of the year.
- When, at the start of a new plan year, your plan drops coverage of a drug or imposes new restrictions on that drug. (change in formulary)
- When you experience a change in level of care. (Examples: moving from a hospital to nursing home, moving from a nursing home to home, etc.)
What are transition rights?
If you are eligible for transition rights based on one of the circumstances above, you can receive the following benefit.
Plans must provide a one-time fill (30 day supply unless a lesser amount is prescribed) of an ongoing medication within the first 90 days of plan membership.
- Applies both to drugs not on formulary and to those subject to utilization management controls.
- Applies to the first 90 days in the plan, even if not at the beginning of the year, and even if the 90-day period extends over two plan years (such as if you enroll in November).
- Applies to new members and to continuing members when a plan has changed formulary.
- Does not cover non-Part D drugs
- Does not cover multiple fills. (For example: if a doctor prescribes a pain medicine in 14-day batches, the transition will only cover one batch.)
- Safety edits are permitted (such as quantity limits based on FDA recommendations, and early refill edits).
If the Plan provider can not determine whether a newly written prescription is for ongoing drug therapy or not, the plan must assume that the prescription is ongoing and apply transition policies.
Does the Plan have any other responsibilities?
If you receive a transition fill, your plan must mail a written notice to you explaining that the transition supply is temporary. They must include instructions on how to file an exception request. The notice must be mailed within 3 business days of the temporary fill.
Residents in Long Term Care facilities get additional benefits
- Plans must provide a 31-day supply during the first 90 days.
- Plans must honor multiple 31-day fills during the first 90 days.