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When can I get a transition fill or temporary supply of my Medicare Part D prescription drugs?

Category: Transition Fills
Updated: Aug, 27 2022


You can get a 30-day temporary or transition prescription drug fill if you:
  • stayed with the same Medicare Part D prescription drug plan (or Medicare Advantage plan that includes drug coverage) into the next year or

  • joined a new Medicare Part D prescription drug plan (PDP or MAPD) and find that your medications are not covered on your newly chosen Medicare Part D plan's formulary or drug list or

  • find that one of your Medicare Part D medications is covered by your newly chosen plan, but the new drug plan has usage management restrictions such as Quantity Limits, Prior Authorization or Step Therapy preventing you from filling your prescription.
Reminder:  You usually have a 90-day period after joining a new Medicare drug plan to use your transition fill.

As noted by the Centers for Medicare and Medicaid Services (CMS):
"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."
As background . . .

If you find that your new Medicare prescription drug plan does not cover one of the medications that you were using before (or has added usage management restrictions to the use of the formulary medication), then there are at least three steps you can take:

Step 1 If your medication is still a part of the Medicare program, you can ask your Medicare prescription drug plan for a one-time 30-day transition fill or temporary supply of your medication.

Reminder:  Sometimes a particular medication is excluded from the Medicare Part D program and will not be available through your Medicare Part D plan - or a drug is subject to additional usage controls, such as opioids.

Step 2 While you are using the temporary medication supply (transition fill), you and your physician can seek an alternative drug that is included on your plan’s formulary.  You can use our Formulary-Browser.com to find and view your plan’s drug list online.

If your medication now has prior authorization or other Usage Management restrictions, you can work with your prescriber to obtain prior authorization approval.

Step 3You can file a formulary exception with your Medicare Part D plan requesting that your non-formulary medication be covered under your new Medicare plan. Learn more about requesting a formulary exception or you can read more about the prescribing physician’s role in the formulary request process. 

Reminder:  Your doctor must submit a statement supporting your formulary exception request and the statement must indicate that the requested drug is medically necessary for treating your condition because none of the drugs on our formulary would be as effective as the requested drug or would have adverse effects for you.

If your formulary exception request involves a waiver of the usage management requirements (prior authorization, quantity limit), your doctor should indicate that the usage management restriction should be waived based on your condition.

(Possible Step 4) Remember: Your Medicare Part D plan will not automatically grant your formulary exception or coverage determination request, but if your request is denied, you have the right to appeal your plan’s decision a number of times, ultimately with review by an independent group. You can call your plan or see an overview of the appeals process here.

Here are a few more details on transition fills:
  • Question:  Is this just a one-time fill for my non-formulary medication?

    In general, yes.
      However, if you have filed a formulary exception and your Medicare plan has not yet made a determination on your request, the Medicare plan must provide an additional transition fill while you are waiting for the plan's decision.  You can read more about getting an extension to your transition fill.

  • Question:  Can I get a transition or temporary fill if I use a non-Part D drug that is not covered on my plan's formulary?

    No (unless used to treat medically-accepted indications). 
    Transition fills are only for medications covered by the Medicare Part D program.  If the FDA finds that a medication is harmful, the drug may be dropped from the Medicare Part D program, and you will not be allowed a transition fill - in such a case, you would need to work with your physician or prescriber to find an alternative medication that is covered by Medicare and your Medicare Part D plan.  You can read more about transition fills and excluded or non-Part D drugs here: https://Q1FAQ.com/698.html

  • Question:  Can I get a transition fill if I am enrolled in a Medicare Advantage plan that includes prescription drug coverage (MAPD)?

    Yes.
      You can request a transition fill if you are enrolled in a stand-alone Medicare Part D plan (PDP) or a Medicare Advantage plan that includes drug coverage (MAPD).

  • Question:  Can I get a transition fill for a new prescription?

    That is not the intent of the transition fill policy.
      Transition fills are for medications that you were using previously and that are no longer covered by your new Medicare Part D plan (or now have usage management restrictions).  If you have a new prescription and the drug is not covered by your Medicare plan, you can ask your plan for a formulary exception whereby you are requesting that your new non-formulary drug be added to your Medicare plan coverage.

    CMS notes:
    "CMS is aware that it may be difficult for Part D sponsors to distinguish between new prescriptions for non-formulary Part D drugs and refills for ongoing drug therapy involving non-formulary Part D drugs. CMS believes a minimum of a 108 day look-back (consistent with other reviews) is typically needed to adequately document ongoing drug therapy. Although Part D sponsors may be able to access prior drug claims history for an enrollee of an affiliated plan, or may attempt to follow up with prescribing physicians and pharmacies to ascertain the status of a prescription presented during the transition period, CMS clarifies that if a sponsor is unable to make this distinction at the point of sale, the sponsor is required to provide the enrollee with a transition fill. In other words, for transition purposes, a brand-new prescription for a non-formulary drug will not be treated any differently than an ongoing prescription for a non-formulary drug when a distinction cannot be made at the point of sale." [emphasis added]

  • A note on transition fills and Long-Term Care (LTC) facilities:

    Transition fill rules for Medicare beneficiaries that reside in a LTC facility transition are slightly more generous.  The Medicare Part D plan must provide a transition fill "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)." [emphasis added]

  • Question:  Will my Medicare Part D plan notify me about receiving (or denying) a transition refill?

    Yes. 
    As per CMS, the Medicare plan notice "must include the following elements:

    1. That the transition supply provided is temporary;

    2. That the enrollee should work with the sponsor as well as his or her health care provider to satisfy utilization management requirements or to identify appropriate therapeutic alternatives that are on the sponsor’s formulary;

    3. That the member has the right to request a formulary exception, the time frames for processing the exception, and the member's right to request an appeal if the sponsor issues an unfavorable decision; and

    4. The sponsor’s procedures for requesting a formulary exception.

    So, you may notice that your Medicare plan provides something like:
    "As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.  You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during your transition to our plan.  For each of your drugs that is not on our formulary or your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days."
Examples of when you can get a transition fill

Here are some other examples of the transition fill notifications and denials that you might receive from your Medicare Part D plan:
  1.  "This drug is not on our formulary. We will not continue to pay for this drug after you have received the maximum 30/102 day supply that we are required to cover unless you obtain a formulary exception from the Medicare Part D plan."

  2.  "This drug is not on our formulary.  In addition, we could not provide the full amount that was prescribed because we limit the amount of this drug that we provide at one time. This is called quantity limits and we impose such limits for safety reasons. In addition to imposing quantity limits as this drug is dispensed for safety reasons, we will not continue to pay for this drug after you have received the maximum 30/102 day supply that we are required to cover unless you obtain a formulary exception from the Medicare Part D plan."

  3.  "This drug is on our formulary, but requires your doctor or other professional who prescribed this drug to satisfy certain requirements before we pay for this drug. This is called prior authorization. Unless you obtain a prior authorization from the Medicare Part D plan, we will not continue to pay for this drug after you have received the maximum 30/102 day supply that we are required to cover."

  4.  "This drug is on our formulary. However, we will only pay for this drug if you first try other drug(s), specifically Step Therapy Drugs as part of what we call a step therapy program. Step therapy is the practice of beginning drug therapy with what we consider to be a safe and effective, lower cost drug before progressing to other more costly drugs. Unless you try the other drug(s) on our formulary first or you obtain an exception to the step therapy requirement from the Medicare Part D plan, we will not continue to pay for this drug after you have received the maximum 30/102 day supply that we are required to cover."

  5.  "This drug is on our formulary. However, we will only pay for this drug if you first try a generic version of this drug [or step therapy]. Unless you try the generic drug on our formulary first, or you obtain an exception from the Medicare Part D plan, we will not continue to pay for this drug after you have received the maximum 30/102 day supply that we are required to cover."

  6.  "This drug is on our formulary. However, we could not provide the full amount that was prescribed because of plan quantity limits. We will not provide more than what our quantity limits permit, which is the Quantity Limit, unless you obtain an exception from the Medicare Part D plan. Please contact the Medicare Part D plan to discuss the exception process. The Medicare Part D plan contact information is located on your Member ID card or all printed Medicare plan documents."
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)






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