Baylor Scott & White Medicare Part D Transition Coverage

Coverage Criteria

Transition supply coverage

Covered when ALL of the following apply for enrollees needing transition fills

Eligibility categories: Enrollee is a newly eligible Medicare enrollee, a new enrollee following the annual coordinated election period, an enrollee who switches plans after the contract year start, a current enrollee affected by negative formulary changes, or a resident of a long-term care (LTC) facility.

Derived from CMS transition requirements

Applicable drugs: Drug is a non-formulary Part D drug, or a Part D drug on the Plan Sponsor's formulary that requires prior authorization or step therapy or has an approved quantity limit lower than the enrollee's current dose under the Plan Sponsor's utilization management.

Includes P&T-approved non-formulary criteria and medical review process

Transition supply amounts: Retail: at least a 30-day supply (unless the prescription is written for less). LTC: at least a 30-day supply or larger when the smallest package exceeds a month's supply, with refills as needed; after the transition period for LTC residents, an emergency supply of at least 31 days (unless written for less) or larger when smallest package exceeds 31 days.Retail >=30 days; LTC >=30 days; Emergency LTC >=31 days

Applies during the first 90 days of enrollment

Protected classes: Enrollees transitioning on drugs in CMS's six protected classes (antidepressants, antipsychotics, anticonvulsants, antineoplastics, antiretrovirals, immunosuppressants) must be granted continued coverage for the duration of treatment or active enrollment; utilization management (PA/ST) is not applied to transitioning enrollees on these agents.

Six protected classes listed in policy

POS processing: Point-of-sale PA/ST/QL edits are overridden during the transition period except for determinations related to Part A/B versus Part D coverage, prevention of non‑Part D drug coverage, or safety-related edits (e.g., opioid safety, FDA maximum dose, early refill edits).

Automated override process and pharmacy help desk support available

Per policy, automated point-of-sale edits for prior authorization, step therapy, and quantity limits are overridden during the transition period except in limited scenarios. Edits are NOT overridden when a Part A/B versus Part D determination is needed, when suppression would allow coverage of drugs that are not Part D, or when necessary to promote safe utilization (for example, beneficiary-level opioid claim edits, FDA maximum dose limits such as APAP, or early refill safety edits).

This transition policy applies to non-formulary Part D drugs and to Part D drugs on the formulary that are subject to utilization management (PA, step therapy, or a quantity limit that would reduce the enrollee's current dose). The Plan Sponsor conducts medical review of non-formulary requests using P&T‑approved criteria and, where an exception is not granted, will assist enrollees in identifying therapeutically appropriate formulary alternatives. Cost‑sharing for transition supplies is applied consistent with regulatory limits and plan rules.

If an exception request undergoes medical review and is not deemed medically necessary, the Plan Sponsor will provide the enrollee and the prescriber with the reason for denial and, when appropriate, information on available formulary alternatives.

There are no additional explicit 'not medically necessary' statements in this section beyond the standard medical review and denial-notification procedures described elsewhere in the policy.

Provider Actions & Requirements

Prior Authorization

Prior authorization / Step therapy application after transition

If an enrollee receives a transition supply at point-of-sale, CMS‑approved prior authorization (PA) and step therapy (ST) requirements are not enforced until the transition supply is exhausted. However, PA/ST requirements may be applied after the transition supply is used. For drugs subject to PA or ST only on new starts, if the pharmacy cannot determine ongoing use at POS and the initial fill is allowed as a transition, the enrollee will thereafter be treated as a current utilizer and new-start PA/ST requirements will not be re‑imposed following that first fill.

PA/ST edits are overridden at POS for transition fills and reactivated only after transition supply exhaustion.
For new-start-only PA/ST rules, once the initial transition fill is accepted the enrollee is treated as ongoing user and new-start rules no longer apply.

Step Therapy

Step therapy instructions

Transition notices provided to enrollees and prescribers must explain the temporary nature of the supply, instruct how to satisfy utilization management requirements or identify covered therapeutic alternatives, and describe the procedures and timelines to request a formulary exception and appeal an adverse decision.

Definitions

inv-15: Emergency Supply — CMS-defined one-time transition fill for enrollees outside initial transition period in LTC

DefinitionA one-time transition fill defined by CMS that is necessary for enrollees who are outside their initial transition period and who reside in a long-term care (LTC) setting.

Applicable settingLong-Term Care (LTC) residents only for emergency supply after the regular transition period has expired.

Minimum emergency supply amountAt least a 31-day supply unless the prescription is written for less than 31 days.

PurposeProvides time to request a formulary exception or authorization after the enrollee's initial transition period has ended.

Regulatory sourceDefined and required by CMS transition rules referenced in the Plan Sponsor policy.

inv-16: Prior Authorization (PA) — process to make benefit determinations prior to medication delivery

Initial Therapy Handling

Initial therapy handling

Treatment starts vs ongoing therapy at point-of-sale (POS)

New vs ongoing distinction: If the POS cannot distinguish a brand-new prescription from ongoing therapy, the Plan Sponsor's transition processes are applied; for drugs with PA or ST that apply to new starts only, enrollees shall be treated as current utilizers if the initial fill is allowed because POS cannot determine ongoing use, and those new-start PA/ST requirements will not be applied after the first fill is provided.

Ensures initial fills are treated as continuation when uncertainty exists

Continuation & Temporary Supply Rules

Protected class continuation

Continuation of therapy during transition for protected class drugs

Protected class continuation: For enrollees transitioning on drugs in the CMS six protected classes (antidepressants; antipsychotics; anticonvulsants; antineoplastics; antiretrovirals; immunosuppressants), the Plan Sponsor provides continued coverage for the duration of treatment or up to the full duration of active enrollment; utilization management (PA and/or step therapy) is not applied to transitioning enrollees already on therapy with these agents.

Six protected classes listed in policy

Temporary supply and transition notice requirements

Rules for temporary supplies and communication during transition

Transition communication and supply actions: Provide a temporary transition supply per setting rules; send written notice to the enrollee within 3 business days of adjudication of the temporary transition fill (for LTC residents dispensed multiple supplies in <=14‑day increments, send within 3 business days of adjudication of the first temporary fill). The notice must explain the temporary nature of the supply, the enrollee's right to request a formulary exception and appeal timeframes, instructions for working with the Sponsor and prescriber to satisfy utilization management or identify covered therapeutic alternatives, and how to request an exception or PA; make PA/exception forms available by mail, fax, email, and on the Sponsor's/PBM's website.

Step Therapy During Transition

Situation	Step therapy during transition	When ST reapplies
Enrollee receiving a transition supply at point-of-sale when POS cannot distinguish new start vs ongoing therapy	Step therapy requirements are overridden for the duration of the transition supply (ST not applied at POS while transition supply is provided)	Applicable step therapy requirements apply after the enrollee has exhausted the transition supply; for drugs with ST that apply to new starts only, the enrollee is treated as a current utilizer after the initial transition fill and ST for new starts no longer applies

Notice element	Required instruction to enrollee/prescriber	Operational detail
Explanation of temporary nature of transition supply	Inform enrollee and prescriber that the supply is temporary and advise steps to obtain ongoing coverage	Must state the supply is temporary and include guidance to work with the Sponsor and prescriber to satisfy ST or request a formulary exception
Instructions for satisfying utilization management (including step therapy) or identifying alternatives	Provide instructions on how to satisfy ST requirements or identify covered therapeutic alternatives on the formulary	Include procedures for working with the Sponsor and prescriber to satisfy UM requirements or to identify alternative covered therapies
How to request a formulary exception and appeals rights	Describe the enrollee's right to request a formulary exception and appeal timelines	Must explain exception request procedures, processing timeframes, and the right to appeal an unfavorable decision; make PA/exception forms available via mail, fax, email, and website
Provider notification and available forms	Notify prescribers of affected enrollees and provide PA/exception forms upon request	Reasonable efforts to notify prescribers (cover letter and confidential patient profile by mail or fax); forms available via mail, fax, email, and Sponsor/PBM website; Sponsor may use CMS model notice or submit non-model for review

Quantity Limits & Supply Duration

inv-23: Non-formulary Part D drugs — temporary supply and partial fills policy

ScopeApplies to non‑formulary Part D drugs provided under the Plan Sponsor's transition process and to situations where quantity limits would otherwise restrict the written days' supply.

Minimum supplyAt least a one‑month (>=30 days) supply is provided in many retail transition cases; LTC temporary fills follow LTC rules (see LTC-specific provisions).

Partial fills and refillsAllow partial fills up to the written amount when a quantity limit or safety edit enforces a smaller dispense; refills are provided to complete the prescribed days' supply while the enrollee pursues an exception or alternative therapy.

Example behaviorIf a QL limits a prescription to 14 days despite a 30‑day written prescription, the enrollee receives 14 days initially and is entitled to the remaining days via subsequent fills consistent with the transition refill policy.

Site of Care Rules

Billing Rule

Minimum transition supplies by setting; suppress early refill edits

Provide at least a 30-day transition supply in retail settings and at least a 30-day (or larger when package size requires) supply with refills as needed in LTC; suppress early refill edits during level-of-care changes and, for LTC residents after transition period, supply an emergency fill of at least 31 days (unless written for less) to allow time for an exception or authorization.

Retail minimum transition supply: at least 30 days during first 90 days of enrollment
LTC transition supply: at least a 30-day supply or larger when smallest package exceeds a month, with refills as needed
Emergency LTC supply after transition: at least 31 days (unless written for less)
Suppress early refill edits during admission/discharge or level-of-care changes

Background

This policy implements CMS‑mandated transition protections to prevent interruptions when a beneficiary's existing drug therapy is not included on a new plan's formulary or is subject to utilization management. It requires the Plan Sponsor to provide a temporary supply appropriate to the site of care (for example, at least a 30‑day retail supply or applicable long‑term care minimums), treat protected‑class drugs as continuing therapy during transition, and furnish a written transition notice within 3 business days of adjudication explaining the temporary nature of the supply, how to request a formulary exception, appeals rights, and procedures to satisfy utilization management or identify alternatives.

OpenPayer

Medicare Part D Transition Policy