Medicare Part D Transition and Emergency Fill
Customize your policy alerts
Sign up for care_continuum Policy n04231 alerts
Get alerted when Policy n04231 changes without checking for updates manually.
Monitor payer policy activity
Defines NHIC's process for providing temporary transition fills and emergency supplies of Part D drugs for Medicare beneficiaries, including eligibility, dispensing limits, notices, and point-of-sale handling; applies to NHIC Prescription Drug Plan enrollees under CMS contracts H5215 and H5644.
Minor grammatical updates were approved at the P&T committee on 07/09/2025.
Added back reference to H5644 contract to allow for addition of EGWP plans with this option (P&T approved 07/10/2024).
Removed reference to H5644 contract (P&T approved 07/12/2023).
Changed Policy Owner (P&T approved 07/13/2022).
Transition and Emergency Fill Coverage Criteria
Point-of-Sale Messaging, Rejects, and Regulatory Citations
| Plan Limits Exceeded | hard reject condition returned at point of sale when transition supply exceeds plan limits |
| If Level of Care Change Call Help Desk | hard reject condition instructing pharmacy to contact help desk when level-of-care change detected |
| Maximum Daily Dose Exceeded | hard reject condition when daily dose exceeds allowed maximum |
| Refill Too Soon | hard reject condition triggered by early refill edits |
| Med B/D Determination Required | hard reject condition requiring Part B vs Part D coverage determination |
| Med D/Non-D Determination required | hard reject condition requiring determination of Part D versus non-Part D coverage |
| Short Cycle Fill | hard reject condition related to short cycle fill rules |
| Part A versus D Determination required | hard reject condition requiring verification of Part A versus Part D coverage |
| 42 CFR 423.120(b)(3) | Transition Process |
| Medicare Prescription Drug Benefit Manual Chapter 5, Section 50.12 | Pharmacy Access During a federal Disaster or Other Public Health Emergency Declaration |
| Medicare Prescription Drug Benefit Manual Chapter 6, Section 30.4 | Transition |
Provider Responsibilities and Exception Handling
Temporary authorization and exception handling
NHIC will authorize a temporary (transition or emergency) fill while a prior authorization/exception request or appeal is pending; providers and pharmacies may obtain prior authorization and exception request forms from NHIC or its delegate via mail, fax, email, or the plan website. Case‑by‑case extensions of the transition period will be made when exception requests or appeals have not been processed by the end of the minimum transition period, and LTC pharmacies may be authorized up to at least a 31‑day emergency fill when necessary information to process an exception is not available.
- Temporary fills allowed while PA/exception is requested; soft edits implemented at point‑of‑sale to enable temporary fills (claims process without hard edits).
- Prior authorization/exception request forms available to enrollees and prescribers via mail, fax, email, and the plan website.
- Case‑by‑case extension of the transition period until switch to formulary alternative or decision on exception/appeal.
- LTC emergency fills: authorize up to at least a 31‑day supply while exception/PA is requested when information to process the exception is unavailable.
P&T oversight of transition-related utilization management
The Pharmacy & Therapeutics (P&T) Committee must review and approve the Medicare Transition Policy annually and provide oversight for transition decisions involving enrollees stabilized on non‑formulary drugs or on‑formulary drugs subject to prior authorization, step therapy, or quantity limits.
- P&T reviews/approves the Medicare Transition Policy on an annual basis.
- P&T involvement ensures transition decisions appropriately address stabilized enrollees on non‑formulary drugs and on‑formulary drugs subject to Prior Authorization, Step Therapy, and Quantity Limits.
Definitions and Eligibility
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.