However, if a long-term care resident exceeds the initial 90 day limit, the Medicare plan can provide a 31-day Emergency Supply of the medication.
Question: What is a transition fill?
The Centers for Medicare and Medicaid Services (CMS) states:
"A Part D sponsor must provide for an appropriate transition process for certain enrollees who are prescribed Part D drugs that represent ongoing therapy with that drug, but that are non-formulary. 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 reference please see: 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)
A note on drugs excluded from the Part D program. If your prescription medication is now excluded from the Medicare Part D program, the medication will not be covered by the transition fill policy. (Learn more about drugs excluded from the Medicare Part D program: see: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/ downloads/PartDDrugsPartDExcludedDrugs.pdf) Where can you learn more?
You may notice in your Medicare drug plan's Evidence of Coverage (EOC) document a description of transition fills that may state something like:
"In the retail setting, non-LTC beneficiaries are eligible to receive at least a one-time temporary fill of at least a month’s supply of medication (unless the prescription is written for less than a month’s supply of medication in which case [the Part D drug plan] will allow multiple fills up to a total of one month’s supply of medication) anytime during the first 90 days of a beneficiary’s enrollment in a plan, beginning on the beneficiary’s effective date of coverage. Greater than a month’s supply will be provided when the drug is prepackaged and cannot be dispensed at a lower day supply.
In the long-term care [LTC] setting, LTC beneficiaries are eligible to receive a one month temporary fill of at least a month’s supply (unless the enrollee presents with a prescription written for less), which will be dispensed incrementally as applicable under (42 CFR 423.154) and with multiple fills provided if needed during the first 90 days of a beneficiary’s enrollment in a plan, beginning on the beneficiary’s effective date of coverage.
In the long-term care setting [LTC], after the transition period has expired, [the Part D drug plan]’s transition policy
provides for a 31-day emergency supply of non-formulary Part D drugs or formulary Part D drugs that require prior authorization, or step therapy and/or have quantity limits (unless the enrollee presents with a prescription written for less than 31 days) while an exception or prior authorization is requested. Greater than a 31-day supply will be provided when the drug is prepackaged and cannot be dispensed at a lower day supply."
Reference:
The Centers for Medicare and Medicaid Services (CMS), Medicare Prescription Drug Benefit Manual Chapter 6 – Part D Drugs and Formulary Requirements, 30.4 - Transition, Section 30.4.4.2 - Timeframe and Transition Supply in the Long Term Care [LTC] Setting (Rev. 18, Issued: 01-15-16, Effective: 01-15-16; Implementation: 01-15-16) - as updated by:
"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