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."
Question: Can any drug be covered by a transition fill?
No. A 30-day transition fill does not apply to any non-formulary drug
that is excluded from the Medicare program. For example, if the medication "Drug ABC" has been banned by the FDA because of possible dangers to the user, a Medicare plan is required to remove "Drug ABC" from the plan's formulary. And although a person may have used "Drug ABC" last year, since the non-formulary drug is excluded from the Medicare program, a transition fill will not be granted to protect the Medicare beneficiary from the dangers associated with this medication.
In addition, if a formulary drug is now covered by
usage management restrictions (such as
Quantity Limits (QL)), people who are using certain protected medications, such as
opioids, may find that their transition fill request for a larger quantity beyond the new-QL is not granted due to additional restrictions placed on these drugs.
Question: How long do I have to get a transition fill?
A 30-day transition fill is only valid for the
first 90 days
after joining the Medicare plan. It is possible to ask your plan for
an extension beyond the 90-day period if you are still waiting for your
plan's formulary exception request determination.
Question: What will I pay for the transition fill?
25% to 50% of the drugs retail cost. Transitions fills are
not free and a person will pay
the cost-sharing associated
with the medication as if they had a formulary exception request
granted and the plan was covering the medication (possibly as a Tier 4
or Tier 5 Specialty Drug with a 25% or more cost sharing).
Question: Are transition fills available to people in a nursing home or long-term care facility?
Yes. In fact, the rules surrounding transition fills within a
long-term care (LTC) facility are more relaxed (or generous) and may extend to providing the non-formulary drugs for at least 91 days or more.