Part D Prescription Drug Transition Policy
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Temporary supply and transition procedures for Part D prescription drugs for Aspirus Health Plan Medicare members during enrollment changes, level-of-care changes, or pending coverage determinations; affects new and current members in retail and long-term care settings.
No material clinical or coverage changes in this revision.
Coverage Criteria — Transition Supplies
Retail Transition
Retail transition — covered when ALL of the following are met
Applies to retail setting.
Long-Term Care Transition
Long-term care (LTC) transition — covered when ALL of the following are met
Applies to long-term care setting; multiple fills allowed to meet 31-day supply; emergency supply available while exception is processed.
Transition Extension
Transition extension — covered when ALL of the following are met
Member or representative must call Customer Service to request extension.
Some medications do not qualify for temporary transition coverage because they are excluded from Medicare prescription drug benefits or require a separate Part B vs Part D coverage determination. Examples include weight loss drugs, cosmetic drugs, over-the-counter (OTC) drugs, medications that need a Part B versus Part D determination, and Medicare-covered drugs prescribed for a non‑approved indication. These products may be denied transition supplies and providers should verify coverage pathway before dispensing.
Provider Actions, Notices, and Operational Steps
Temporary coverage during prior authorization/step therapy
Aspirus Arise provides temporary coverage for Part D drugs when members cannot immediately access their regular medications. This temporary supply applies to drugs that are on the formulary but require prior authorization or step therapy, and to non‑formulary Part D drugs in eligible transition situations. The temporary coverage is limited and intended to allow time for prior authorization, step‑therapy completion, or formulary/coverage resolution.
- Retail transition: at least a 30‑day temporary supply for new members or members affected by new formulary restrictions within the first 90 days of eligibility; includes formulary drugs requiring prior authorization or step therapy.
- LTC transition: at least a 31‑day temporary supply for new LTC residents or LTC members affected by new formulary restrictions within the first 90 days of eligibility; includes formulary drugs requiring prior authorization or step therapy.
- LTC emergency supply: multiple fills may be authorized as needed up to 31 days while an exception is processed or during transition period.
- Temporary coverage does not remove the requirement for prior authorization/step therapy; it simply provides a short supply while those processes are completed.
Temporary coverage during step therapy
When a step‑therapy requirement applies, Aspirus Arise will provide a temporary supply so the member is not left without medication while meeting the step‑therapy requirements. Retail and long‑term care settings have distinct temporary supply rules.
- Retail: at least a 30‑day temporary supply for members in transition; includes drugs on the formulary that require step therapy.
- Long‑term care: at least a 31‑day temporary supply and the plan may honor multiple fills as needed up to a 31‑day supply while step‑therapy requirements are addressed.
- If the prescription is written for less than the minimum transition supply, the plan will provide the quantity written.
Drugs excluded from Medicare coverage or requiring Part B vs Part D review
Some drugs are not eligible for the Part D transition process because they are excluded from Medicare Part D coverage or require a Part B vs Part D determination. Providers should verify coverage eligibility before relying on transition supplies.
- Examples of exclusions: weight‑loss drugs, cosmetic drugs, over‑the‑counter (OTC) drugs, and other drugs excluded from Medicare coverage.
- Drugs requiring Part B vs Part D determination or Medicare‑covered drugs prescribed for a non‑approved indication may not qualify for transition.
- If a drug is excluded from Part D or requires a Part B determination, standard transition supplies will not be provided; submit a coverage determination request if appropriate.
Member notice and information
Aspirus Arise will send written notice to members within three business days of the transition fill explaining that the supply is temporary and providing instructions on next steps.
- Notice will include how to work with the prescriber to find an alternative medication, how to request a formulary exception, and the cost‑sharing amount for the one‑time transition based on drug tier and Extra Help status.
- Members may call customer service (number on member ID card) or TTY 1.855.931.4852 for assistance; customer service hours 8 am–8 pm, seven days a week.
Definitions and Key Terms
Background and Scope
This policy ensures continuity of therapy by providing short-term supplies of Part D medications when members experience coverage disruptions due to enrollment changes, formulary changes, level-of-care transfers, or pending coverage determinations. It applies to members in both retail and long-term care settings and is intended to bridge therapy while prior authorizations, step therapy requirements, formulary exceptions, or appeals are processed.
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