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