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If my medications are now subject to drug restrictions (prior authorization) is it possible to get a transition fill while requesting a formulary exception?

Category: Formulary Exceptions (Coverage Determinations)
Updated: Jan, 23 2023

Yes.  According to the Centers for Medicare and Medicaid Services (CMS), the transition fill policy will apply to both non-formulary Part D drugs and
“Part D drugs that are on a sponsor’s formulary but require Prior Authorization or Step Therapy or that have an approved [Quantity Limits] QL lower than the beneficiary’s current dose, under a plan’s utilization management requirements [UM]."
CMS continues on to state that,
"a formulary drug whose access is restricted via UM requirements is essentially equivalent to a non-formulary Part D drug to the extent that the relevant UM requirements are not met for a particular enrollee.”
However, CMS does also note that:
"if the plan’s [quantity limit or] QL is equal to an FDA maximum dose limit, plans do not have to allow doses greater than this limit as part of a transition supply."

A Reminder about Usage Management Restrictions

Even if you did not change Medicare prescription drug plans, it is possible that your new Medicare prescription drug plan has implemented some form of utilization management restrictions (also known as drug restrictions or drug usage management restrictions) in their formulary to keep costs down and protect their plan members from drug interactions or drug over-usage.

Utilization management includes such prescription controls as:
  • Quantity Limits (for example, only allowing plan members 30 tablets per 30 days) or

  • Prior Authorization (requiring members to get plan approval before filling a prescription) or

  • Step Therapy (having members try lower-costing medications before using a more expensive drug).
Please remember:
Just like when asking your plan to cover a non-formulary drug, you have the right to ask your plan for a formulary exception (or Coverage Determination) if you wish to be exempt from a specific usage management requirement.  Click here to learn how to request a formulary exception.

Examples of how your Medicare plan will inform you of Usage Management Restrictions

Your Medicare prescription drug plan documentation (Evidence of Coverage) may provide text such as the following to explain how your formulary is controlled and how you can deal with usage management restrictions:

  • "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."

  • "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."

  • "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."

  • "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: 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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