Dear Marci,
A drug that I need to take is not on my Part D prescription drug plan’s formulary. My friend told me that my plan might need to provide me with a transition refill of this prescription. What does this mean?
-Ezra (Portland, OR)
Dear Ezra,
A transition refill, also known as a transition fill, is a one-time, 30-day supply of a drug that you were taking:
- Before switching to a different Part D plan (either stand-alone or through a Medicare Advantage Plan)
- Or, before your current plan changed its coverage at the start of a new calendar year.
Transition fills let you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions (such as prior authorization or step therapy).
Transition fills are not for new prescriptions. You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage.
The following situations describe when you can get a transition refill if you do not live in a nursing home (there are different rules for transition refills for those living in nursing homes):
1.Your current plan is changing how it covers a Medicare-covered drug you
have been taking.
- If your plan is taking your drug off its formulary or adding a coverage restriction for the next calendar year for reasons other than safety, the plan must either:
- Help you switch to a similar drug that is on your plan’s formulary before January 1
- Or, help you file an exception request before January 1, 2020
- Or, give you a 30-day transition fill within the first 90 days of the new calendar year along with a notice about the new coverage policy.
2.Your new plan does not cover a Medicare-covered drug you have been
taking.
- If a drug you have been taking is not on your new plan’s formulary, this plan must give you a 30-day transition refill within the first 90 days of your enrollment. It must also five you a notice explaining that your transition refill is temporary and informing you of your appeal rights.
- If a drug you have been taking is on your new plan’s formulary but with a coverage restriction, this plan must give you a 30-day transition refill free from any restriction within the first 90 days of your enrollment. It must also give you a notice explaining that your transition refill is temporary and informing you of your appeal rights.
- In both of the above cases, if a drug you have been taking is not on your new plan’s formulary, be sure to see whether there is a similar drug that is covered by your plan (check with your doctor about possible alternatives) and, if not, to file an exception request. (If your request is denied, you have the right to appeal.)
Note: If you file an exception request and your plan does not process it by the end of your 90-day transition refill period, your plan must provide additional temporary refills until the exception is completed.
Remember: All stand-alone Part D plans and Medicare Advantage Plans that offer drug coverage must provide transition fills in the above cases. When you use your transition fill, your plan must send you a written notice within three business days. The notice will tell you that the supply was temporary and that you should either change to a covered drug or file an exception request with the plan.
-Marci
