(An Evidence of Coverage document should have been sent to you when you enrolled in your Medicare Part D drug plan - or your plan will provide you with a link where you can download an electronic copy of the EOC document - if necessary, you can telephone your Medicare plan and ask for a copy of your EOC.)
As a reminder, a transition fill is a temporary one month's prescription supply or refill of a non-formulary drug provided during the first 90 days of enrollment to:
- People who have stayed with the same Medicare drug plan into
the next year and now find that their existing 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 that their prescription medications are not covered by their newly chosen Medicare
Part D plan's formulary or drug list or
- People who find 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.
- But, a transition fill does not apply to any non-formulary drug that is excluded from the Medicare program. As noted by the Centers for Medicare and Medicaid Services (CMS):
Learning more from your plan's Evidence of Coverage:"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."
You Evidence of Coverage is an extensive (150+ page), printed document that you receive when first enrolling into a Medicare Part D plan and also receive each year with your Annual Notice of Change (ANOC) letter that is mailed to you in late-September or early-October. In your Evidence of Coverage document you should find some text such as:
"[i]f [the Medicare Part D plan agrees] to make [a formulary exception] and cover a drug that is not in the [plan's drug list], you will need to pay the cost-sharing amount that applies to drugs in Cost-Sharing Tier 4 - Non-Preferred drugs. You cannot ask for [another formulary] exception to [lower] the copayment or coinsurance amount we require you to pay for the drug."or you may read...
"If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Cost-Sharing Tier 3: Non-Preferred Drug. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug."
... or...
"[Medicare plan ABC] ensures that appropriate cost-sharing amounts are applied to the transition supply claims. Cost-sharing for a temporary supply of drugs will never exceed the statutory maximum co-payment amounts for low-income subsidy (LIS) eligible beneficiaries. For non-LIS eligible beneficiaries, [Medicare plan ABC] will apply the same cost sharing for non-formulary Part D drugs provided during the transition that would apply for non-formulary drugs approved through a formulary exception in accordance with §423.578(b) and the same cost sharing for formulary drugs subject to utilization management edits provided during the transition that would apply if the utilization management criteria are met."
This information should be found in a section entitled "What is an exception?", about 100 +
pages into the EOC document.
You can review our Formulary Browser to see your plan’s cost-sharing for Tier 3 or Tier 4 or Tier 5 medications.
You can also telephone your Medicare drug plan's Member Services department and ask about the cost-sharing when a formulary exception is granted for the coverage of a non-formulary drug. The toll-free number for Member Services is found on your Member ID card.
Question: So, how much can you expect to pay for your transition fill of a non-formulary drug if it listed as a Tier 3 or 4 Non-Preferred drug?
Probably around 25% to 50% of the non-formulary drug's retail cost. Your Medicare Part D plan will charge you the same cost-sharing amount as you would pay if a formulary exception request had been granted and your non-formulary drug was being covered by your Medicare Part D prescription drug plan.
As seen in the examples above, if your Medicare plan agrees to cover a non-formulary drug, you may be asked to pay the cost-sharing associated with Tier 3 or 4 Non-Preferred drugs - even when your non-formulary drug is a low-costing generic. This means that you will be paying a percentage of the drug’s retail cost (25% to 50% of retail).
For more information about the cost of a transition fill, please see our FAQ: "How much will I pay for the transition fill of a non-formulary drug?"