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

Medicare Part D Transition Policy

Governs the Plan Sponsor's Medicare Part D transition processes for non-formulary and managed drugs, describing temporary fills, overrides, and procedures affecting enrollees (including LTC) for BSWIC Medicare and BSWHP Medicare lines of business.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part D Transition Policy

Policy CodePolicy BSWHP.DPS.123.P

Change TypeRevised transition periodadministrative updates

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionOverride POS prior authorization and step therapy edits during an enrollee's transition period while ensuring safety edits and Part A/B determinations remain enforced.

SourceLink

POLICY UPDATE CHANGES

Revised 90 day transition period to 108 day transition period and updated Plan Name to Baylor Scott & White Health Plan (BSWHP).

Updated policy language to align with OptumRx and Capital Rx Medicare Transition Policies for various plan years (CY2024-CY2025-CY2026).

Removed H4943 which will not be active in 2026.

Documented effective date and approvals for 05/19/2025 and P&P Committee approval 05/23/2025.

30 daysminimum retail transition supply

31 daysminimum LTC emergency supply after transition expiration

108 dayslookback period minimum

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CMS Six Protected Classes

42 CFR §423.120(b)(3)regulatory authority

108 daysrevised transition period

Transition Coverage and Supply Criteria

Transition Coverage Criteria

Covered when ALL of the following apply:

Eligible enrollees include new enrollees after the annual coordinated election period, newly Medicare-eligible beneficiaries, enrollees who switch plans mid-year, current enrollees affected by negative formulary changes across contract years, and enrollees residing in long-term care (LTC) facilities.

Applies to Part D drugs that are not on the Plan Sponsor's formulary and to Part D drugs on the formulary that require prior authorization or step therapy or that have an approved quantity limit lower than the enrollee's current dose under the Plan Sponsor's utilization management rules.

The Plan Sponsor provides a temporary transition supply to address immediate needs and allow time to request a formulary exception or to work with the prescriber to switch to a therapeutically equivalent formulary alternative; the P&T committee's non-formulary criteria and medical review/exception processes apply as described in policy.

Six Protected Classes: Antidepressants, Antipsychotics, Anticonvulsants, Antineoplastics, Antiretrovirals, and Immunosuppressants (for transplant prophylaxis) must be granted continued coverage for the duration of treatment or active enrollment; utilization management (PA/ST) are not applied to transitioning enrollees on these agents (except for new enrollees naïve to therapy).

PA, step therapy, and quantity limit edits are applied after the enrollee has exhausted the transition supply as appropriate; for drugs with PA or ST on new starts only, an initial allowed transition fill treats the enrollee as a current utilizer thereafter.

Edits at point-of-sale that would otherwise prevent payment are overridden during the transition period except where needed to determine Part A vs Part D coverage, prevent coverage of non-Part D drugs, or to promote safe utilization (e.g., opioid beneficiary-level edits, FDA maximum dosing quantity limits, early refill safeguards). An automated transition fill process permits payment without a pharmacist hard-override.

The Plan Sponsor may deny quantities or doses during transition when FDA maximum recommended dosing or P&T-established clinical limits are exceeded; prior to denial the Plan Sponsor will verify an initial transition supply has been provided and that the enrollee or prescriber was assisted in filing an exception or that an exception was processed.

Transition period may be extended on a case-by-case basis until exception requests or appeals are resolved and an appropriate therapeutic transition or approval is made.

When a prescription cannot be distinguished as new versus ongoing at point-of-sale, the transition process is applied; CMS-approved PA, ST, or QL requirements are applied only after the transition supply is exhausted.

For negative formulary changes across contract years, transition protections are provided at the new contract year start when enrollee paid-claim history meets lookback requirements (policy describes lookback and cross-year application).

Transition Supply Coverage Criteria

Covered when ALL of the following apply:

Temporary transition fills are provided to enrollees for non-formulary and utilization-managed Part D drugs to address immediate needs; early refill edits are suppressed for level-of-care changes to permit appropriate access.

Retail setting: a minimum transition supply of at least a 30-day supply (based on the Plan Sponsor's approved bid) is provided anytime during the first 90 days of enrollment, unless the prescription is written for less; multiple fills up to a month's supply are allowed when written for less or when the smallest package exceeds a month's supply.

LTC setting: a temporary fill of at least a 1-month supply (or a larger days' supply where the smallest package exceeds a month or multiple packages are required) is provided with refills as needed during the first 90 days; after the transition period expires, LTC residents receive at least a 31-day emergency supply while an exception or prior authorization is requested (or a larger days' supply when package/unit constraints apply).

Refills are allowed for transition prescriptions dispensed for less than the written amount due to quantity limit or safety edits consistent with approved product labeling; transition supplies may be shortened by QL/safety edits, but refills up to the plan's transition month allowance are permitted.

Regulatory References, POS/NCPDP Messaging, and Safety Limits

Regulatory/edits referencesmixed

42 CFR §423.153(b)

POS PA edits to determine Part A/B vs Part D coverage and excluded drug uses

POS messaging / NCPDPmixed

NCPDP Telecommunication Standard

POS messaging and pharmacy reject/approval codes used during transition; pharmacy messages updated per NCPDP and CMS standards.

Maximum transition supply rules where QL safety edits apply

Refill allowance when QL/safety edits shorten initial fillRefills are allowed for transition prescriptions dispensed for less than the written amount due to quantity limit safety edits or drug utilization edits based on approved product labeling, up to the Plan Sponsor's allowable transition month supply.

Shortened supply exampleIf a prescription is limited by a QL to 14 days for safety, the enrollee receives the 14-day supply and is entitled to the remaining days (e.g., another 16 days) while pursuing an exception or therapeutic switch.

Six protected classes exemptionSix protected class agents are granted continued coverage during transition and utilization management (PA/ST) is not applied to enrollees transitioning on these agents.

FDA safety limits

Authority to deny quantities/doses

Point-of-Sale Overrides, Authorizations and Operational Handling

Prior Authorization

POS Overrides and Authorization Handling

During an enrollee's transition period, pharmacy point-of-sale (POS) prior authorization and step therapy edits for non-formulary Part D drugs are automatically overridden at POS except for edits that: (1) determine Part A versus Part D coverage, (2) prevent coverage of non‑Part D drugs, or (3) promote safe utilization (e.g., opioid safety edits, FDA maximum dosing, early refill edits). Pharmacies may contact Capital Rx's Pharmacy Help Desk for immediate assistance with POS overrides and emergency fills; an automated transition fill process permits payment without a pharmacist hard‑override.

Edits automatically overridden for transition fills except the three categories listed above.
Pharmacies can contact Capital Rx Pharmacy Help Desk for POS overrides and emergency fills.
Automated transition fill process does not require a dispensing pharmacist to enter a 'hard edit' override to permit payment.

Denial Risk

Terminology and Special Cases

Emergency Supply (LTC)

DefinitionEmergency Supply is a one-time transition fill that is necessary for enrollees who are outside their initial transition period and are in the long-term care (LTC) setting.

PurposeProvides immediate medication access for LTC residents who no longer qualify for initial transition fills while an exception or prior authorization is pursued.

Relation to POS overridesPharmacies may contact the PBM Pharmacy Help Desk for immediate assistance with emergency fills as described for current enrollees in the policy.

Prior Authorization (PA), Step Therapy, and Quantity Limits

DefinitionPrior Authorization (PA) is the process to make a benefit determination prior to the intended delivery of a healthcare service, treatment, or supply; includes PA requests for medications designated as 'Prior Authorization Required', 'Step Therapy', or 'Quantity Restrictions'.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Part D Transition Policy

Policy CodePolicy BSWHP.DPS.123.P

Change TypeRevised transition periodadministrative updates

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionOverride POS prior authorization and step therapy edits during an enrollee's transition period while ensuring safety edits and Part A/B determinations remain enforced.

SourceLink

On This Page

PA and step therapy edits are overridden at POS for transition fills except when needed to determine Part A/B coverage, to prevent coverage of non-Part D drugs, or to enforce safety-related edits (opioid limits, FDA maximum dosing, early refill safeguards); automated POS messaging and processing follow NCPDP telecom standards.

Quantities or doses may be denied during transition if they exceed FDA safety limits or well-established clinical practice guidelines used by the P&T committee; before denial the Plan Sponsor will confirm an initial transition supply was provided and that assistance with exception filing occurred.

Cost sharing: LIS enrollees will not be charged more than the statutory maximum copayment for temporary transition supplies; non-LIS enrollees will be charged the same cost sharing that would apply for approved formulary exceptions or utilization management criteria per 42 CFR § 423.578(b).

Transition notice requirements: the Plan Sponsor mails the CMS model written transition notice via first-class mail within 3 business days of adjudication of the temporary transition fill (for LTC residents, within 3 business days of adjudication of the first temporary fill). Notices must explain the temporary nature of the supply, how to work with the sponsor/prescriber, instructions for exception/appeal rights and procedures, and how to request PA/forms. Prescribers are also notified via cover letter and confidential patient profile.

Systems and POS messaging: Capital Rx utilizes current NCPDP Telecommunication Standards for POS messaging; NCPDP reject and approval codes are reviewed and pharmacy messages updated per NCPDP and CMS standards to support transition processing.

The Plan Sponsor posts transition program information on its website and includes the program in enrollment materials; the Plan performs QA checks and ongoing monitoring of systems and performance related to transition services per CMS guidance.

The Plan Sponsor retains authority to deny access to quantities or doses during transition when they exceed FDA safety limits or P&T-established clinical guidelines.

Pre-denial verification stepsBefore denying, the Plan Sponsor verifies an initial transition supply was provided up to the maximum limit and that the enrollee or prescriber was assisted in filing an exception or that an exception was processed.

Examples of safety-promoting editsSafety-promoting edits include beneficiary-level opioid edits, quantity limits based on FDA maximum recommended daily dose (e.g., APAP), and early refill safeguards applied during transition.

Prior Authorization and Transition Edit Handling

The Plan Sponsor verifies that PA and step therapy edits are overridden for transition fills except when needed to determine Part A/B vs Part D coverage, to prevent coverage of non‑Part D drugs, or to enforce safety‑promoting utilization edits. An automated transition fill process allows payment without pharmacist override; however, exception requests and appeals remain available and are processed expeditiously. The Plan Sponsor may deny quantities or doses that exceed FDA safety limits or P&T‑established clinical limits only after ensuring an initial transition supply was provided and assistance with filing an exception was offered or an exception processed.

Exceptions where PA/ST edits are not overridden: Part A/B determination, non‑Part D exclusions, and safety/utilization edits (e.g., beneficiary‑level opioid edits, FDA maximum dosing, early refill edits).
Denials for excess quantities/doses may be made only after providing initial transition supply and assisting with or processing an exception request.

Includes Step Therapy and Quantity LimitsPA encompasses step therapy (ST) — requiring trials of other medications — and quantity limits (QL) as types of utilization management considered under PA processes.

Role in transition handlingPA/ST/QL edits are generally overridden at point-of-sale during an enrollee's transition period except for Part A/B determinations, exclusion of non-Part D drugs, and safety-promoting edits.

Level of Care Changes

DefinitionLevel of Care Changes are changes from one treatment setting to another (e.g., entering or leaving an LTC facility, discharge from hospital to home, ending a Medicare Part A SNF stay, reverting from hospice, discharge from psychiatric hospital) that may trigger transition fills.

Effect on early refill editsEarly refill edits are suppressed during level of care changes to avoid limiting access to Part D benefits during the transition between settings.

NCPDP submission codesSpecific NCPDP pharmacy submission clarification codes may be used to allow transition fills for each level of care change.

Unplanned transitions requiring temporary fills

Examples of unplanned transitionsAdmission to a hospital or LTC facility; discharge from a hospital to home; end of a Medicare Part A SNF stay; reversion from hospice to standard Medicare; discharge from psychiatric hospital with highly individualized regimens.

Temporary fill handlingEarly refill edits are not used to limit access and are suppressed during these unplanned transitions to permit necessary temporary transition fills.

Use of NCPDP codesPharmacies may use specific NCPDP submission clarification codes to document and process transition fills related to unplanned level-of-care changes.

Cost Share Considerations

LIS cost-sharing capFor Low-Income Subsidy (LIS) eligible enrollees, cost-sharing for temporary transition supplies will never exceed the LIS statutory maximum copayment amount.

Non-LIS enrollees cost-sharingFor non-LIS enrollees, the Plan Sponsor will charge the same cost sharing for non-formulary Part D drugs provided during the transition process that would apply for non-formulary drugs approved through a formulary exception per 42 CFR § 423.578(b).

Utilization management parityThe same cost sharing applies for formulary drugs subject to utilization management edits provided during transition that would apply if the utilization management criteria are met.