CurrentFlorida Complete CarePolicy N/A

Part D Transition Guidelines

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This policy governs how Florida Complete Care provides temporary Part D medication supplies when drugs are not on the formulary or are subject to prior authorization, quantity limits, or step therapy. It applies to new and existing Part D members, including members in long-term care and members undergoing changes in level of care.

Policy Summary

PayerFlorida Complete Care

PolicyPart D Transition Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReview requests for temporary supplies involving non-formulary Part D drugs or drugs subject to utilization-management restrictions, and evaluate medically necessary exceptions or appropriate formulary alternatives.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysStandard transition period for new Part D members

At least 1 monthMinimum temporary supply in outpatient and LTC settings

31 daysMinimum emergency supply for qualifying LTC members

3 business daysDeadline for written transition notice

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CurrentFlorida Complete CarePolicy N/A

Part D Transition Guidelines

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Sign up for all floridacompletecare policy alerts

Know when floridacompletecare releases new policies or updates existing guidance.

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Policy Summary

PayerFlorida Complete Care

PolicyPart D Transition Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysStandard transition period for new Part D members

At least 1 monthMinimum temporary supply in outpatient and LTC settings

31 daysMinimum emergency supply for qualifying LTC members

3 business daysDeadline for written transition notice

14 days or lessLTC dispensing increment addressed by special notice rule

Eligibility, Supply Rules, and Cost Sharing

Eligibility and administration of Part D transition supplies

A temporary transition supply may be provided when the member and medication meet the applicable transition circumstances and supply rules.

Utilization-management edits during transition are limited to determining Part A or Part B versus Part D coverage, preventing coverage of non-Part D drugs or non-medically accepted uses, and promoting safe use of a Part D drug.

An exception or appeal may be requested, and the transition period may be extended case by case when the request remains unprocessed at the end of the minimum transition period.

A written notice is sent within 3 business days after delivery or adjudication of the first temporary supply, explaining its temporary nature, next steps with the plan and prescriber, the right to request a formulary exception, and the exception procedures.

Transition-supply cost sharing

Cost sharing applies to transition supplies.

For members not eligible for LIS, cost sharing is consistent with the cost sharing for non-formulary drugs approved through a coverage exception or for formulary drugs subject to the applicable utilization-management edit after its criteria are met.

For LIS-eligible members, cost sharing never exceeds the applicable legal maximum copayment amounts.

Transition Supply Timing and Quantities

Initial transition period

DurationFirst 90 days of coverage

Start dateBeginning on the member's coverage effective date

Applies toRetail, home infusion, long-term care, and mail-order pharmacies

Outpatient temporary supply

Minimum supplyAt least one month of Part D medication

Prescription exceptionThe supply may be shorter if the prescription is written for less than one month

Applicable drugsNon-formulary Part D drugs and formulary drugs requiring prior authorization, exceeding quantity limits, or requiring step therapy

Operational Responsibilities

Prior Authorization

Review transition requests and alternatives

Review requests for temporary supplies involving Part D drugs that are not on the formulary or that require prior authorization, exceed quantity limits, or require step therapy. When medically necessary, evaluate formulary exceptions and therapeutically appropriate formulary alternatives.

Prior Authorization

Coordinate exceptions, appeals, and extensions

Process or support exception and appeal requests while the member receives transition coverage. Extend the transition period case by case when the exception or appeal has not been processed by the end of the minimum transition period.

Documentation Required

Handle unplanned level-of-care transitions

Key Terms and Roles

Transition supply

DefinitionA temporary medication supply provided during the applicable transition period

Drug scopePart D drugs that are not on the formulary or that require prior authorization, exceed quantity limits, or require step therapy

PurposeProvides time to satisfy utilization-management requirements, request an exception, or identify an appropriate formulary alternative

LTC

MeaningLong-term care

Included membersMembers residing in a long-term-care facility

Relevant transitions

Policy Summary

PayerFlorida Complete Care

PolicyPart D Transition Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

LTC temporary supply

Minimum supplyAt least one month for a new member in an LTC facility

Dispensing incrementsThe supply follows the facility's dispensing increments

RefillsRefills are provided as needed during the first 90 days of enrollment, beginning on the member's coverage effective date

Prescription exceptionThe supply may be shorter if the prescription is written for less

LTC emergency supply

Minimum supplyAt least 31 days of Part D medication

Dispensing incrementsThe 31-day minimum applies regardless of dispensing increments

Prescription exceptionThe supply may be shorter if the prescription is written for less than 31 days

Transition notice deadline

Standard deadlineWithin 3 business days after delivery of the first temporary supply

LTC dispensing ruleFor LTC residents receiving multiple supplies in 14-day or shorter increments, the notice is due within 3 business days after adjudication of the first temporary supply

Notice contentExplain the temporary nature of the supply, next steps with the plan and prescriber, the right to request a formulary exception, and the exception procedures

Annual contract transition timing

ANOC timingThe Annual Notice of Change is sent before September 30

Process timingFlorida Complete Care initiates the transition process for current members at or before the beginning of the new contract year

New November or December enrolleesThe transition policy also applies to members with an effective enrollment date of November 1 or December 1 who need a transition supply

For unplanned changes in level of care, make coverage determinations and redeterminations as quickly as the member’s health condition requires. Support appropriate medication reconciliation when the member is discharged from long-term care or another facility.

Billing Rule

Obtain point-of-sale override when needed

When claims data cannot establish that the member experienced a change in level of care, the pharmacy may contact Customer Service to process a point-of-sale override for the transition supply.

Documentation Required

Coordinate prescriber follow-up

Work with the plan and prescriber to satisfy utilization-management requirements or identify appropriate formulary alternatives. Notify prescribers of transition fills when reasonably possible to facilitate the member’s transition.

Members entering or leaving a long-term-care facility, including changes between hospital, facility, and community settings

LIS

MeaningLow-income subsidy eligibility

Cost-sharing limitCost sharing for transition supplies may not exceed applicable legal maximum copayment amounts

ApplicationThe limit applies to members eligible for the low-income subsidy

Pharmacy and Therapeutics Committee

Committee typeAn advisory committee

MembershipPrimary-care physicians, specialty physicians, and pharmacists

Medication roleReviews clinical medication information and recommends formulary decisions

ANOC

MeaningAnnual Notice of Change

TimingSent to members before the next contract year

PurposeProvides advance notice of formulary or benefit changes