CurrentAspirus ArisePolicy N/A

Medicare Part D Prescription Drug Transition Policy

Defines Aspirus Health Plan's temporary prescription refill (transition) process for Part D drugs for new members, members experiencing formulary changes, and long-term care residents, including emergency supply and extension rules.

Policy Summary

PayerAspirus Arise

PolicyMedicare Part D Prescription Drug Transition Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSend written notice to members within three business days of the transition fill explaining the temporary nature of the supply, how to work with providers to find alternatives, and how to request a formulary exception.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30minimum retail transition supply

31minimum LTC/emergency transition supply

90transition eligibility window (days)

Medicare Part D Transition Coverage Criteria

General Transition Eligibility (retail setting)

Provide temporary supply of non-formulary Part D drugs when ALL of the following apply:

Policy Summary

PayerAspirus Arise

PolicyMedicare Part D Prescription Drug Transition Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Transition Eligibility (long-term care setting)

Provide temporary supply in LTC when ALL of the following apply:

ALL of the following

Member is a new enrollee in Aspirus Health Plan within the first 90 days of eligibility
Or current member living in long-term care facility who is taking medication(s) no longer covered or subject to new formulary restrictions within the first 90 days of the new contract year
Includes Part D drugs that require prior authorization or step therapy.

Transition supply — long-term care and emergency supply

When eligible in LTC or during an emergency while exception is processed:

ALL of the following

Provide temporary or emergency supply of non-formulary Part D drugs for at least 31 days
Unless prescription is written for less than 31 days.
Honor multiple fills as necessary to provide up to a 31-day supply
If member is outside the 90-day transition period, an emergency supply will still be provided while an exception is being processed

Level of care changes

Transition process also applies when ALL of the following occur:

ALL of the following

Member has a level of care change such as admission to or discharge from a long-term care facility or other institution
Discharge planning is completed before the member is discharged
Notices that a refill is 'too soon' will be waived to prevent delays.

Actions, Notices, and Prior Authorization

Documentation Required

Notices to member

Aspirus Health Plan will send written notice to members within three business days of the transition fill, stating the transition supply is temporary, explaining how to work with the provider to find another medication that may be available and appropriate, and explaining the member’s right and instructions to request a formulary exception.

Prior Authorization

Exception/appeal processing and extension

If an exception request or appeal is pending at the end of the minimum transition period, providers or members may request a transition extension by contacting Aspirus Health Plan Medicare Advantage Plans Customer Service; the plan will extend the transition on a case-by-case basis until the exception or appeal is decided or the medication is changed.

Denial Risk

Excluded drugs from transition

Certain drugs may not qualify for the Part D transition and may require a coverage determination before transition is allowed. Examples include excluded Medicare drugs, over-the-counter (OTC) products, weight-loss or cosmetic drugs, drugs requiring a Part B vs Part D coverage determination, and Medicare-covered drugs prescribed for a non‑approved indication.

Policy Background and Purpose

This policy implements the Medicare Part D transition requirement to provide members with a temporary supply of medications when they cannot obtain their drugs due to enrollment, formulary changes, or level-of-care changes. The intent is to ensure continuity of therapy while prior authorizations, exceptions, or appeals are processed and a longer-term coverage decision is made. Examples of covered situations include new enrollees within the first 90 days of eligibility, members affected by formulary changes early in the contract year, and residents of long-term care facilities who require immediate access to non-formulary Part D drugs or drugs subject to prior authorization or step therapy.

Aspirus Health Plan will provide a temporary retail supply for at least 30 days (unless the prescription is written for less than 30 days) and a temporary long-term care or emergency supply for at least 31 days (unless the prescription is written for less than 31 days). In the long-term care setting, multiple fills may be honored as needed to provide up to a 31-day supply. If an exception or appeal remains pending at the end of the minimum transition period, the plan may extend the transition on a case-by-case basis until the exception/appeal is decided or the medication is changed to a formulary alternative.

Certain drugs may not qualify for transition and could require a coverage determination before transition is allowed (for example, excluded Medicare drugs, over-the-counter products, weight-loss or cosmetic drugs, drugs requiring a Part B vs Part D determination, or drugs prescribed for non-approved indications). The plan will send written notice to members within three business days of a transition fill explaining the temporary nature of the supply, how to work with their provider to find alternatives, and instructions to request a formulary exception.

OpenPayer

Medicare Part D Prescription Drug Transition Policy

Medicare Part D Transition Coverage Criteria

Transition Timeframes and Minimum Supplies

Actions, Notices, and Prior Authorization

Policy Background and Purpose

Defined Terms