Prescription Benefits Medicare Part D Transition Policy
Medicare Part D Transition Policy
What can you do if your drug is not on the Drug List or if the drug is restricted in some way?
If your drug is not on the Drug List or is restricted, here are things you can do:
- You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
- You can change to another drug.
- You can file an exception and ask the plan to cover the drug or remove restrictions from the drug.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is not on the plans Drug List.
- or the drug you have been taking is now restricted in some way (Section 5 in this chapter tells about restrictions).
- You must be in one of the situations described below:
- For those members who were in the plan last year and aren't in a long-term care facility:
We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply or less if your prescription is written for fewer days.
- For those members who were in the plan last year and aren't in a long-term care facility:
We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
- For those members who are new to the plan and reside in a long-term-care facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply), or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
- For those members who have been in the plan for more than 90 days and reside in a a long-term care facility:
We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
Exceptions:
Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows:
- For example if a beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital.
- Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary.
- Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits.
- Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized.
All of these situations would warrant a temporary one-time fill exception regardless of whether the beneficiary is in their first ninety (90) days of program enrollment.
During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an Exception for you by filling out the following NPS Coverage Determination Request Form.
H8578_2016_049 Approved
The information on this page was last updated on 2/18/2016