Medicare Part D Prescription Drug Transition Policy
Customize your policy alerts
Sign up for all Aspirus Arise policy alerts
Know when Aspirus Arise releases new policies or updates existing guidance.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
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:
ALL of the following
- Member is a new enrollee in Aspirus Health Plan within the first 90 days of eligibility
- Or current member who is taking medication(s) no longer covered or subject to new formulary restrictions within the first 90 days of the new contract year
This includes Part D drugs on formulary that require prior authorization or step therapy.
Transition supply — retail
When eligible in retail setting:
ALL of the following
- Provide temporary supply of non-formulary Part D drugs for at least 30 days
Unless the prescription is written for less than 30 days.
- Applies to Part D drugs that are on the formulary but require prior authorization or step therapy
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.
Transition extension
When the exception request or appeal is not decided by the end of the minimum transition period, Aspirus may extend the transition on a case-by-case basis. The extension ends when ANY of the following occur:
ANY of the following
- The medication is changed to another formulary drug
- The exception request or appeal is decided
Transition Timeframes and Minimum Supplies
Actions, Notices, and Prior Authorization
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.
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.
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.
Defined Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.