ModifiedBaylor Scott & White Health PlanPolicy BSWHP.DPS.123.P

Medicare Part D Transition Policy

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Governs the Medicare Part D transition program for temporary coverage of non-formulary or utilization-managed drugs, including transition fills, emergency supplies, formulary exceptions, and pharmacy processing for BSWHP Medicare and BSWIC Medicare enrollees in retail and long-term care settings.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part D Transition Policy

Policy CodePolicy BSWHP.DPS.123.P

Change TypeModified

Effective DateJan 1, 202747d

Last ReviewJun 26, 2026

Next Review DateN/A

Key ActionDuring transition, providers and pharmacies may pursue a formulary exception, prior authorization, or switch to a therapeutically equivalent formulary medication while the enrollee receives temporary coverage.

SourceLink

POLICY UPDATE CHANGES

The transition period was revised from 90 days to 108 days in a prior policy revision.

The 2026 revision updated the policy for the 2027 plan year and made minor grammatical changes.

30 daysMinimum retail transition period

90 daysInitial enrollment transition period

31 daysMinimum LTC emergency supply

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ModifiedBaylor Scott & White Health PlanPolicy BSWHP.DPS.123.P

Medicare Part D Transition Policy

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Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part D Transition Policy

Policy CodePolicy BSWHP.DPS.123.P

Change TypeModified

Effective DateJan 1, 202747d

Last ReviewJun 26, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

The transition period was revised from 90 days to 108 days in a prior policy revision.

The 2026 revision updated the policy for the 2027 plan year and made minor grammatical changes.

30 daysMinimum retail transition period

90 daysInitial enrollment transition period

31 daysMinimum LTC emergency supply

Negative formulary change lookback

6Protected drug classes

3 business daysWritten notice deadline

Medicare Part D Transition Coverage

Medicare Part D Transition Coverage Criteria

Transition coverage applies when ALL applicable conditions below are met.

ALL of the following

ONE of the following drug conditions
- The Part D drug is not on the Plan Sponsor's formulary.
- The drug is on the formulary but requires prior authorization or step therapy under the Plan Sponsor's utilization management requirements.
- The drug is on the formulary but has an approved quantity limit lower than the enrollee's current dose.
ONE of the following enrollee or coverage circumstances
- The enrollee is within the first 90 days of enrollment, beginning on the effective date of coverage, and presents a prescription for a non-formulary Part D drug.
- The enrollee is a current enrollee affected by a negative formulary change at the start of a new contract year and has a paid claim history for the drug within the designated lookback period.>= 108-day lookback period
- The Plan Sponsor effectuates transition coverage before the beginning of the new contract year for a current enrollee affected by a negative formulary change.
- The enrollee is transitioning into a plan with an effective enrollment date of November 1 or December 1, and transition supplies extend across contract years.
- The enrollee resides in a long-term care facility and requires a transition or emergency supply.
The Plan Sponsor provides a temporary supply while the enrollee and/or prescriber works toward a therapeutically equivalent formulary alternative or submits a formulary exception request based on medical necessity.
The Plan Sponsor conducts medical review of the non-formulary request and applies the applicable exception criteria, including medication trial and failure when applicable, appropriate diagnosis, contraindication or adverse event or harm from formulary alternatives, and whether a formulary alternative is likely to be less effective.

Temporary Part D Transition Supply Criteria

Temporary transition supplies are provided when ALL applicable criteria below are met, subject to the prescription and setting-specific rules.

ALL of the following

ONE of the following dispensing settings
- Outpatient or retail setting
  - The enrollee is within the first 90 days of enrollment, beginning on the effective date of coverage.
  - A temporary supply of at least a one-month supply is provided, unless the prescription is written for less.>= 30 days
  - If the prescription is written for less than one month, multiple fills may be provided up to a total one-month supply.
- Long-term care setting during the transition period

Level-of-Care Transition Criteria

Level-of-care transition protections apply when ALL of the following are met.

ALL of the following

ONE of the following unplanned changes
- The enrollee is admitted to a hospital.
- The enrollee is admitted to a long-term care facility.
- The enrollee is discharged from a hospital or long-term care facility to the home.
- The enrollee changes from one treatment setting to another.
The change creates an immediate need to maintain access to the enrollee's Part D benefit.

Pharmacy Transition Submission Messaging

Pharmacy transition processing must satisfy ALL applicable submission and notice requirements.

ALL of the following

The pharmacy claim is processed through the automated transition-fill process; a dispensing pharmacist is not required to enter an override code or hard edit to permit payment of a non-formulary drug claim.
For an unplanned level-of-care transition, the pharmacy may use the applicable NCPDP pharmacy submission clarification code to identify the transition and permit a transition fill.
NCPDP reject and approval codes, pharmacy messages, and point-of-sale messaging are maintained and updated in accordance with the current NCPDP Telecommunication Standard and CMS standards and guidelines.
The transition notice identifies the temporary nature of the supply, explains how to satisfy utilization management requirements or identify a covered therapeutic alternative, explains the right to request a formulary exception and appeal, states applicable processing timeframes, and describes how to request an exception.

Transition Supply Parameters and Processing

Retail transition period

Minimum retail supplyAt least 30 days

Enrollment windowDuring the first 90 days of enrollment, beginning on the effective date of coverage

Prescription exceptionIf the prescription is written for less, multiple fills up to a total of a month’s supply are allowed; larger supplies may apply when the product cannot be broken

LTC transition supply

Initial LTC supplyAt least a month’s supply during the first 90 days of enrollment

Dispensing incrementsRefills are provided as needed, consistent with the applicable dispensing increment under 42 CFR §423.154 in the LTC setting

Provider and Pharmacy Responsibilities

Prior Authorization

Manage Non-Formulary Therapy

During the transition period, pursue a formulary exception, prior authorization, or switch to a therapeutically equivalent formulary medication for a non-formulary Part D drug.

Non-formulary drugs include drugs not on the formulary and formulary drugs subject to prior authorization, step therapy, or a lower quantity limit than the enrollee's current dose.
Temporary supplies allow time to complete an exception request or work with the prescriber on an appropriate formulary alternative.

Documentation Required

Support Medical Necessity Exceptions

Support medical-necessity exception requests with the clinical information required by the Plan Sponsor's non-formulary criteria.

Document medication trial and failure, when applicable.
Provide the diagnosis and any contraindication, adverse event, or potential harm associated with formulary alternatives.

Policy Terms

Centers for Medicare and Medicaid Services (CMS)

AgencyCenters for Medicare and Medicaid Services (CMS)

Government roleAn agency within the U.S. federal government

ResponsibilityCharged with execution and maintenance of the law defining the prescription drug program for senior citizens, people with disabilities, and the infirm

Emergency Supply

Type of supplyA one-time transition fill

When usedFor enrollees outside their initial transition period

Setting

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part D Transition Policy

Policy CodePolicy BSWHP.DPS.123.P

Change TypeModified

Effective DateJan 1, 202747d

Last ReviewJun 26, 2026

Next Review DateN/A

SourceLink

On This Page

The enrollee is within the first 90 days of enrollment, beginning on the effective date of coverage.
A temporary fill of at least a one-month supply is provided, with refills as needed and consistent with the applicable LTC dispensing increment under 42 CFR §423.154, unless the prescription is written for less.>= 30 days

Long-term care setting after the transition period

The enrollee remains in a long-term care facility after the transition period has expired.
An emergency supply of a non-formulary Part D drug is provided while an exception or prior authorization is requested, unless the prescription is written for less than 31 days.>= 31 days

ONE of the following package-size circumstances

The smallest available package size exceeds the applicable one-month or 31-day supply.
Multiple packages are required to achieve a therapeutic dose or use and the resulting supply exceeds the applicable one-month or 31-day supply.

For transition prescriptions dispensed for less than the written amount because of quantity-limit safety edits or drug-utilization edits based on approved product labeling, refills are allowed.

During transition, prior authorization and step-therapy edits are overridden unless an exception applies for Part A versus Part B coverage determination, prevention of coverage for a non-Part D drug, or safe utilization of a Part D drug.

Cost sharing for the temporary supply complies with transition requirements: it does not exceed statutory maximum copayment amounts for LIS-eligible enrollees; for non-LIS enrollees, non-formulary drugs use the cost sharing applicable to formulary exceptions and formulary drugs subject to utilization management use the cost sharing applicable when utilization management criteria are met.

The enrollee receives appropriate transition notice within a reasonable time after the temporary supply, with written notice sent by U.S. first-class mail within three business days of adjudication of the temporary transition fill submit date. For LTC residents receiving multiple supplies in increments of 14 days or less, notice is sent within three business days of adjudication of the first temporary fill submit date.within 3 business days

Early refill edits are suppressed and are not used to limit access during the level-of-care change.

A transition fill may be submitted using the applicable NCPDP pharmacy submission clarification code for the unplanned transition.

Reasonable efforts are made to notify the prescriber of record, including by first-class mail or facsimile, with a cover letter and confidential patient profile identifying the patient, address, drug filled, and reason for notification.

The CMS model Transition Notice is used.

Prescription exceptionsA larger supply may apply when the product cannot be broken, the smallest unit exceeds a month’s supply, or multiple packages are needed for a therapeutic dose; a prescription written for less is honored

LTC emergency supply

Minimum emergency supplyAt least 31 days after the transition period expires

PurposeTo allow time to request a formulary exception or prior authorization

ExceptionsA shorter prescription is honored; a larger supply may apply when the product cannot be broken, the smallest unit exceeds 31 days, or multiple packages are needed for a therapeutic dose

Negative formulary change lookback

Lookback periodA minimum of 108 days

Applicable enrolleesCurrent enrollees whose drugs are affected by negative formulary changes from one contract year to the next

Qualifying historyThe enrollee must have a history of paid claim(s) for the drug within the designated lookback period

Written transition notice timing

Mailing deadlineWithin 3 business days of adjudication of the temporary transition fill submit date

Multiple LTC suppliesFor LTC residents receiving multiple supplies in increments of 14 days or less, the notice is sent within 3 business days of adjudication of the first temporary fill submit date

Notice formatWritten notice is sent by U.S. first-class mail using the CMS model Transition Notice

Safety-based denial prerequisites

Initial supply prerequisiteAn initial transition supply must be provided up to the maximum limit

Exception assistance prerequisiteThe enrollee or prescriber must be assisted in filing an exception, or the exception must have been processed

When applicableThese prerequisites apply before denying quantities or doses that exceed FDA safety limits or limits based on peer-reviewed medical literature or established clinical practice guidelines

Pharmacy transition submission messagingNDC

NCPDP clarification codes

Pharmacy submission clarification codes may support transition fills during level-of-care changes.

Explain when a formulary alternative is likely to be less effective for the enrollee.

If the request is not medically necessary, the enrollee and prescriber receive the denial reason and available formulary alternatives when appropriate.

Billing Rule

Apply Limited Utilization Management

During transition, apply only permitted utilization-management edits at point of sale. Prior authorization and step-therapy edits associated with non-formulary drugs are generally resolved through the transition process, subject to the stated exceptions.

Determine whether coverage is under Medicare Part A or Part B rather than Part D.
Prevent coverage of non-Part D or excluded drugs, including drugs used for non-medically accepted indications.
Apply safe-utilization edits, such as opioid safety edits, FDA-based quantity limits, and early-refill edits.
Refills must be provided for transition prescriptions shortened by approved quantity-limit or drug-utilization safety edits, up to the Plan Sponsor's allowable transition supply.

Prior Authorization

Protect Six Protected Drug Classes

Do not apply prior authorization or step therapy to a transitioning enrollee who is taking a drug in one of CMS's six protected classes, subject to applicable coverage and safety exceptions.

Protected classes: antidepressants, antipsychotics, anticonvulsants, antineoplastics, antiretrovirals, and immunosuppressants for prophylaxis of organ-transplant rejection.
Continue coverage for the duration of treatment or active enrollment, as applicable.
PA and step therapy may be applied to new enrollees who are naive to therapy.

Unsupported block type: info

Unsupported block type: billing_rule

Billing Rule

Transition-Fill Override Exceptions

Verify that prior authorization and step-therapy edits are overridden for transition fills unless a permitted payment or safety exception applies.

Exceptions include determining Part A/B versus Part D coverage, preventing coverage of non-Part D drugs, and promoting safe utilization of a Part D drug.
Permitted safety edits may include beneficiary-level opioid edits, FDA-based quantity limits such as acetaminophen limits, and early-refill edits.
Pharmacies may contact the Capital Rx Pharmacy Help Desk for immediate assistance with point-of-sale overrides, including emergency fills.

Billing Rule

Automated Transition Fill

Process payment for an applicable non-formulary Part D transition fill through the automated transition-fill process without requiring the dispensing pharmacist to enter an override code or hard edit.

The automated process applies during the enrollee's transition period.
Continue to apply the permitted Part A/B, non-Part D, and safe-utilization exceptions.

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Unsupported block type: billing_rule

Note

Prescriber Transition Support

Coordinate with the Plan Sponsor and enrollee after a transition notice to address utilization-management requirements, identify appropriate therapeutic alternatives, or complete a formulary exception request.

Work with the enrollee to switch to a therapeutically equivalent formulary drug when appropriate.
Support requests for formulary exceptions and explain appeal rights and processing timeframes.
Exception and prior-authorization request forms must be made available to prescribing physicians and enrollees through available channels, including mail, fax, email, and the Plan Sponsor or PBM website.
Reasonable efforts are made to notify prescribers of affected enrollees; prescribers should respond to transition notices and provide requested clinical information.

The enrollee is in the long-term care setting

Level of Care Changes

DefinitionA change from one treatment setting to another

Included transitionsEntering an LTC facility from a hospital or other setting, leaving an LTC facility for the community, or discharge from a hospital to home

Other examplesCompletion of a Medicare Part A skilled nursing facility stay, reversion from hospice, or discharge from a psychiatric hospital with highly individualized medication regimens

LTC

AbbreviationLTC

MeaningLong-term care

Policy settingThe term is used for long-term care facility and related transition processes

National Council for Prescription Drug Programs (NCPDP)

OrganizationA 501(c)(3) nonprofit charitable organization

MembershipComprises subject matter experts

RoleProvides guidance and standards on health information technology, such as pharmacy claim adjudication

Prior Authorization (PA)

ProcessThe process undertaken to make a benefit determination before the intended delivery of the healthcare service, treatment, or supply under review

ExamplesIncludes coverage determinations for medications designated as requiring prior authorization, step therapy, or quantity restrictions

ExceptionsAlso includes requests for exceptions for non-formulary medications or a coinsurance amount

Point-of-Sale (POS)

SystemThe PBM’s point-of-sale prescription transaction processing computer system

Claim submissionThe point where the pharmacy submits the retail claim electronically

Transaction timingThe actual retail transaction occurs when the claim is submitted electronically by the pharmacy

Quantity Limit (QL)

TypeA type of utilization management

FunctionLimits the quantity of a medication an enrollee may receive

AbbreviationQL

Step Therapy (ST)

TypeA type of utilization management

RequirementRequires a trial of another medication before another medication may be covered

AbbreviationST

Utilization Management (UM)

PurposeA technique used by insurers, health plans, managed care entities, and payers to manage healthcare benefit costs

AssessmentAssesses appropriateness before covering a drug or service using evidence-based criteria or guidelines

Common techniquesTypically includes prior authorization, step therapy, and quantity limits