"A Part D sponsor must provide for an appropriate transition process for certain enrollees who are prescribed Part D drugs that represent ongoing therapy with that drug, but that are non-formulary. The purpose of providing a transition supply is to promote continuity of care and avoid interruptions in drug therapy while a switch to a therapeutically equivalent drug or the completion of an exception request to maintain coverage of an existing drug based on medical necessity reasons can be effectuated."
"If you are a resident of a long-term care facility, we will cover up to a 90 day transition supply (unless you have a prescription written fewer days). We will cover more than one refill of these drugs for the first 180 days you are a member of our plan while you are a resident of a long-term care facility. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 180 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception"
"The transition supply of non-formulary Part D drugs for a new enrollee in an LTC facility must be for at least 91 days, and may be up to at least 98 days to be consistent with the applicable dispensing increment in the LTC setting (unless a lesser amount is actually prescribed by the prescriber). Part D sponsors must allow multiple fills if needed to provide the full amount of medication prescribed, in accordance with 42 CFR §423.120(b)(3)(iii)(B). If the smallest available marketed package sizes do not align with this time frame, the sponsor must still provide a transition supply when required. Part D sponsors and their processors must determine how to process claims in such cases.
CMS is requiring up to a 91- to 98-day transition supply given that many LTC pharmacies and facilities must dispense brand name medications in 14-day or less increments. Also, sponsors must honor multiple fills of non-formulary Part D drugs as necessary during the entire length of the transition period." [emphasis added]