Part D Transition Policy
2024 transition policy
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 request 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:
1. The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan's drug list.
- The drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below:
- For members who were in the plan last year and aren't in a long-term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy. - For members who are new to the plan and aren’t in an LTC facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we allow multiple fills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy. - For members who were in the plan last year and reside in an LTC facility:
We will cover a temporary supply of your drug during the first 90 days of the calendar year. The total supply will be for a maximum of a 31-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.) - For members who are new to the plan and reside in an LTC facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The total supply will be for a maximum of a 31-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.). - For members who have been in the plan for more than 90 days, reside in an LTC facility, and need a supply right away:
We will cover a 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above LTC transition supply. - Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who:
- Enter LTC facilities from hospitals, who are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short-term planning taken into account (often under eight hours).
- Are discharged from a hospital to a home.
- End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
- End an LTC facility stay and return to the community.
If a member has more than one change in level of care in a month, the pharmacy must call our plan to request an extension of the transition policy.
To ask for a temporary supply, call Member Services.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.