CurrentFidelis CarePolicy N/A

Prescription drug transition and temporary supply rules

Rules governing temporary transition supplies, prior authorization, step therapy, and formulary exceptions for Fidelis Care members, including special provisions for long-term care residents and new admissions.

Policy Summary

PayerFidelis Care

PolicyPrescription drug transition and temporary supply rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribers or members should request a formulary exception or prior authorization while a temporary transition supply is provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-daystandard temporary supply for new members

one-timestandard transition fill allowed only once for new members

34-daytransition supply limit for long-term care residents

up to 2refills allowed for long-term care transition supply

14-dayemergency supply after first 90 days for LTC

Policy Summary

PayerFidelis Care

PolicyPrescription drug transition and temporary supply rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribers or members should request a formulary exception or prior authorization while a temporary transition supply is provided.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

New Member Transition Coverage

Covered when ALL of the following are met

new_member_transition: Member is within the first 90 days of coverage and presents a prescription for a drug that is not on the formulary, requires prior authorization, or is subject to step therapyfirst 90 days

A one-time 30-day supply (unless written for fewer days) may be approved at a network pharmacy; refills after the one approved temporary 30-day supply will not be covered. Only Part D drugs are eligible for transition fills; drugs that may be Part B are excluded.

Long-Term Care Resident Transition Coverage

Covered when ALL of the following are met

ltc_transition: Resident is within the first 90 days of coverage and needs a drug that is not on the formulary, requires prior authorization, or is subject to step therapyfirst 90 days

Up to a 34-day supply with up to two (2) refills (unless written for fewer days) will be covered at network pharmacies.

Long-Term Care Emergency or New Admission Coverage

Covered when ANY of the following are met

ltc_emergency_or_new_admission: Member is a long-term care resident past the first 90 days of enrollment and requires an emergency supply while pursuing a formulary exceptionafter 90 days

An emergency 14-day supply will be covered.

ltc_new_admission: Member is a new admission to a long-term care facility

A 14-day supply will be permitted for new long-term care admissions.

Only drugs that are Part D drugs are eligible for transition fills. Drugs that are Part B drugs, or that could be considered either Part B or Part D, are excluded from transition fill processing and will not be provided a temporary transition supply.

Actions for Prescribers and Pharmacies

Prior Authorization

Prior Authorization and Transition Fill — New Members

New Members: Prior authorization and transition fills may be required. If a prescribed drug is not on the formulary, requires prior authorization, or is subject to step therapy, members or prescribers should request a formulary exception where applicable. A temporary 30-day transition supply may be covered in certain situations during the first 90 days of coverage (unless written for fewer days) when filled at a network pharmacy. Only Part D drugs are eligible for transition fills; drugs that are Part B or may be Part B/Part D are excluded.

Temporary supply approved only once for new members
Only Part D drugs eligible for transition fill

Step Therapy

Step Therapy During Transition

Step therapy may require members to try alternative drugs before coverage for the prescribed agent is allowed. During the transition period you may be eligible for a temporary supply while a prescriber pursues a formulary exception or meets step requirements. Discuss options with the prescriber to determine whether switching to a covered alternative or requesting an exception is appropriate.

Transition supply available while pursuing exception or meeting step therapy requirements
Step therapy may require trying alternatives first

Note

Member Notification

If a formulary exception request is approved, the member will be notified by regular mail within three (3) business days that the prescription can be filled.

Member notification sent via regular mail within three business days of approval

Denial Risk

Limit on Transition Refill Coverage

Limit on Transition Refill Coverage: For new members, a one-time temporary 30-day (unless written for fewer days) transition supply will be approved only once; after that approved temporary supply has been used, additional refills will no longer be covered. For long-term care residents a different rule applies: up to a 34-day supply with up to two refills (unless written for fewer days) may be covered during the first 90 days of coverage. If past the first 90 days, an emergency 14-day supply may be covered while pursuing an exception.

New members: one-time 30-day transition supply only
Long-term care residents: up to 34-day supply with up to two refills during first 90 days
After first 90 days for LTC residents: emergency 14-day supply while pursuing exception

Quantity and Refill Limits for Transition Supplies

Standard temporary supply for new members — 30-day

Quantity limitOne-time temporary 30-day supply (unless written for fewer days)

Eligibility windowMember is within the first 90 days of coverage

Dispensing locationMust be filled at a network pharmacy

Refill restrictionThis 30-day transition supply will be approved only once; additional refills will not be covered

ExclusionsOnly Part D drugs may receive a transition fill; drugs that may be Part B or Part B/Part D are excluded

Transition supply limit for long-term care residents — 34-day

Quantity limitUp to a 34-day supply (unless written for fewer days)

RefillsUp to two (2) refills allowed

Eligibility windowDuring the first 90 days of coverage for long‑term care residents

Coverage triggersWhen drug is not on formulary, requires prior authorization, or is subject to step therapy

Dispensing locationMust be filled at a network pharmacy

Emergency supply after first 90 days for long-term care or new long-term care admissions — 14-day

Quantity limit14-day emergency supply

Applicability after 90 daysCovered for long-term care residents past the first 90 days while pursuing a formulary exception

New long-term care admissionsA 14-day supply is permitted for new admissions to long-term care facilities

PurposeProvides temporary coverage while a formulary exception is pursued

Step Therapy During Transition

Requirement	Details	Coverage status
Step therapy may be required
Member may be required to try an alternative drug first or request a formulary exception to bypass step therapy; transition supplies may be provided while step therapy or an exception is pursued
Covered with criteria
New member transition supply
A one-time temporary 30-day supply (unless written for fewer days) may be approved at a network pharmacy during the first 90 days of coverage; additional refills after the one-time 30-day supply will not be covered
Covered with criteria
Long-term care resident transition
Up to a 34-day supply with up to two (2) refills (unless written for fewer days) may be covered during the first 90 days of coverage; if past 90 days, an emergency 14-day supply may be covered while pursuing a formulary exception
Covered with criteria

Background

This policy outlines administrative transition and temporary supply rules rather than clinical treatment guidance. It describes when Fidelis Care will provide a one-time temporary supply (for example, a 30-day supply for new members during the first 90 days of coverage), where the supply must be filled (a network pharmacy), and how prior authorization, step therapy, and formulary exception processes interact with transition fills. Clinical decisions about changing therapy or starting alternative agents remain the responsibility of the prescriber and member.

OpenPayer

Prescription drug transition and temporary supply rules

Transition and Temporary Supply Coverage Criteria

Actions for Prescribers and Pharmacies

Quantity and Refill Limits for Transition Supplies

Step Therapy During Transition

Where Transition Supplies Must Be Filled

Background