- People who have stayed with the same Medicare drug plan into the next year and, within the first 90 days of the new plan coverage, find that their existing Part D medications are no longer covered by their Medicare plan or
- People who joined a new Medicare Part D prescription drug plan (PDP or MAPD) during the annual Open Enrollment Period (AEP) and find, within the first 90 days, that their prescription medications are not covered by their newly chosen Medicare
Part D plan's formulary or drug list or
- People who find within the first 90 days that their Part D medication is covered by their newly chosen Medicare prescription drug plan, but their Medicare drug plan now has usage management restrictions such as Quantity Limits, Prior Authorization or Step Therapy preventing the plan member from filling their prescription.
As noted by the Centers for Medicare and Medicaid Services (CMS):
Question: Can any drug be covered by a transition fill?"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."
No. A month's transition supply does not apply to any non-formulary drug that is excluded from the Medicare program. For example, if the medication "Drug ABC" has been banned by the FDA because of possible dangers to the user, a Medicare plan is required to remove "Drug ABC" from the plan's formulary. And although a person may have used "Drug ABC" last year, since the non-formulary drug is excluded from the Medicare program, a transition fill will not be granted to protect the Medicare beneficiary from the dangers associated with this medication.
In addition, if a formulary drug is now covered by usage management restrictions (such as Quantity Limits (QL)), people who are using certain protected medications, such as opioids, may find that their transition fill request for a larger quantity beyond the new-QL is not granted due to additional restrictions placed on these drugs.
Question: How long do I have to get a transition fill?
A month's transition fill is only valid for the first 90 days after joining the Medicare plan. However, it is possible to ask your plan for an extension beyond the 90-day period if you are still waiting for your plan's formulary exception request determination.
Question: What will I pay for the transition fill?
25% to 50% of the drugs retail cost. Transitions fills are not free and a person will pay the cost-sharing associated with the medication as if they had a formulary exception request granted and the plan was covering the medication (possibly as a Tier 4 or Tier 5 Specialty Drug with a 25% or more cost sharing).
Question: Are transition fills available to people in a nursing home or long-term care facility?
Yes. Since 2019, the rules surrounding transition fills within a long-term care (LTC) facility are the same as for Medicare Part D beneficiaries who are in a out-patient setting: a one month's supply of a non-formulary Part D drugs or a drug subject to usage management restrictions for the first 90 days with the Part D plan. However, depending on the circumstances, LTC residents can be granted an additional 31-day Emergency Supply of their Part D medications after the first 90 days has expired.
Sources include:
CMS Medicare Prescription Drug Benefit Manual, Chapter 6 – Part D Drugs and Formulary Requirements, Section 30.4 - Transition (Rev. 18, Issued: 01-15-16, Effective: 01-15-16; Implementation: 01-15-16)
"CMS Finalizes Policy Changes and Updates for Medicare Advantage and the Prescription Drug Benefit Program for Contract Year 2019 (CMS-4182-F)"
(https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-policy-changes-and-updates-medicare-advantage-and-prescription-drug-benefit-program)
"Changes to the Days' Supply Required by the Part D Transition Process (§ 423.120)"
https://www.federalregister.gov/documents/2018/04/16/2018-07179/medicare-program-contract-year-2019-policy-and-technical-changes-to-the-medicare-advantage-medicare