CurrentHealthPartnersPolicy N/A

Medicare Part D Medication Transition

Governs one-time transitional pharmacy fills for HealthPartners Medicare Part D enrollees (including newly eligible beneficiaries and long-term care residents) to cover immediate medication needs when formulary or utilization management changes occur.

Policy Summary

PayerHealthPartners

PolicyMedicare Part D Medication Transition

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide a one-time temporary supply (minimum one-month retail or a 31-day LTC emergency supply) to allow time to complete prior authorization, step therapy, or exception requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one-timetemporary transition fill per drug

>=1 monthminimum transitional supply (retail)

90 daystransition window

31 daysLTC emergency supply

Coverage Criteria — Transition Supply for Medicare Part D

inv-01: Eligibility for transition supply

Covered when any of the following enrollee conditions apply:

Eligible enrollee categories: All enrollees to HealthPartners Medicare Part D plans as of January 1 following the Annual Election Period; newly eligible Medicare beneficiaries from other coverage; individuals who switch plans after January 1; enrollees residing in long-term care (LTC) facilities (including those with changes in level of care, e.g., entering an LTC facility or being discharged from a hospital); continuing enrollees affected by negative formulary changes from one contract year to the next.

Supports continuity during transitions

inv-02: Supply duration and setting

Covered supply conditions:

Transition supply conditions: One-time temporary supply of non-formulary Part D drugs or formulary drugs that require prior authorization or step therapy, or that have an approved quantity limit lower than the beneficiary's current dose; provided as at least a one-month supply at retail (or multiple fills totaling up to one month when the prescription is written for less than a month).

Policy Summary

PayerHealthPartners

PolicyMedicare Part D Medication Transition

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide a one-time temporary supply (minimum one-month retail or a 31-day LTC emergency supply) to allow time to complete prior authorization, step therapy, or exception requests.

SourceLink

On This Page

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Supply to allow time to request exceptions or switch to therapeutic alternatives

inv-03: Timing and LTC emergency supply

Timing and additional LTC provision:

Timing: Transition fill available anytime during the first 90 days of the beneficiary's enrollment in a plan beginning on the enrollee's effective date of coverage, or during the first 90 days of the contract year for continuing enrollees.90 days

LTC special provision: Enrollees in LTC receive a one-time temporary supply of at least a month's supply in increments up to a month's supply (with multiple fills as necessary) during the first 90 days; additionally, a one-time 31-day emergency supply of non-formulary drugs is provided while an exception is being processed.31 days

Emergency supply while exception pending

This policy applies specifically to non-formulary Part D drugs and formulary drugs subject to utilization management or with approved quantity limits below the beneficiary's current dose. Non-formulary Part D drugs are defined as Part D medications that are not on the plan formulary, and formulary products that require prior authorization, step therapy, or have a quantity limit insufficient to cover the enrollee's current regimen. The intent is to govern a one-time, temporary transition supply to address immediate medication needs while prescribers, pharmacies, and the plan complete required utilization management or exception requests.

Provider Actions and Notifications

Prior Authorization

Temporary supply while prior authorization/step therapy completed

One-time, temporary supply to allow time for the prescriber and enrollee to complete utilization management requirements (prior authorization or step therapy). HealthPartners will provide a one-time, temporary supply of non-formulary Part D drugs or formulary drugs that require prior authorization, step therapy, or have quantity limits that are insufficient for the beneficiary's current dose. This temporary supply accommodates the enrollee's immediate needs while prior authorization/step therapy or exception requests are completed.

Applies to Part D drugs not on the formulary and to formulary drugs that require prior authorization, step therapy, or have approved quantity limits lower than the beneficiary's current dose.
One-time temporary supply is provided to allow time for prescriber/enrollee to complete utilization management (prior authorization or step therapy) or to request a formulary exception.

Step Therapy

Step therapy during transition

Transition fills cover formulary drugs that would otherwise be subject to step therapy. HealthPartners will provide a one-time temporary fill of at least a 30-day supply (retail) — or multiple fills totaling a 30-day supply if the prescription is written for less than a month — to allow time to meet step therapy requirements or to identify an appropriate therapeutic alternative.

Available anytime during the first 90 days of a beneficiary's enrollment (beginning on the effective date of coverage) or during the first 90 days of the contract year for continuing enrollees.
Retail setting: at least a one-month supply (multiple fills allowed to total one month if necessary).
Long-term care (LTC) residents: one-time temporary supply of at least a month's supply in increments up to a month with multiple fills as needed; additionally, a one-time 31-day emergency supply of non-formulary drugs while an exception is processed.

Note

Post-fill notification

HealthPartners will send written notice to the enrollee within three business days of the transition fill explaining the temporary nature of the supply and next steps.

Explanation that the supply is temporary.
Instructions for working with HealthPartners and the prescriber to satisfy utilization management requirements or to identify therapeutic alternatives when appropriate.
Explanation of the enrollee's right to request a formulary exception and description of the procedures for requesting one.

Note

Triggers for transition

Triggers for the transition policy — when a one-time temporary transition supply may be provided.

Non-formulary Part D drugs (drugs not on the formulary).
Formulary Part D drugs that require prior authorization.
Formulary Part D drugs that are subject to step therapy.
Formulary Part D drugs with an approved quantity limit lower than the beneficiary's current dose.
Immediate needs of the enrollee during the first 90 days of plan enrollment or the first 90 days of the contract year for continuing enrollees.

Initial Transitional Fill Criteria

inv-11: Initial transitional fill

One-time transitional initial fill

Initial transitional fill: Provide a one-time, temporary retail fill of at least one month's supply for non-formulary or restricted formulary Part D drugs to allow time for longer-term coverage arrangements; if the prescription is written for less than a month, permit multiple fills to total a month's supply.1 month

Multiple fills allowed to reach a month's supply if prescription written for less

Continuation During Transition

inv-12: Continuation therapy during transition

Temporary continuation while utilization management/exception is completed

Continuation supply: One-time temporary continuation of the enrollee's current medication (at least a one-month retail supply) during the first 90 days of enrollment or contract year for continuing enrollees; LTC residents may receive multiple fills up to a month's supply or a one-time 31-day emergency supply of non-formulary drugs while an exception is pending.

Intended to permit prescriber and plan to resolve utilization management or seek exception

Step Therapy — Transition Provisions

Situation	Transition fill provided	Coverage label
Formulary drug subject to step therapy that would otherwise block access	One-time temporary supply of up to a 1-month retail fill to allow completion of required step(s) or submission of an exception	Covered with criteria
Non-formulary Part D drug or formulary drug requiring prior authorization or with an approved quantity limit below the beneficiary's current dose	One-time temporary supply of at least a 1-month retail fill (or multiple fills totaling a month if prescription written for less) provided to permit time for prior authorization/exception or therapeutic substitution	Covered with criteria
Long-term care resident needing immediate medication while exception/authorization is pending	One-time temporary supply provided in increments appropriate for LTC up to a month's supply; a one-time 31-day emergency supply of non-formulary drugs is allowed while an exception is processed	Covered with criteria

Quantity Limits and Supply Durations

Quantity limits for non-formulary or restricted formulary Part D drugs

Minimum retail supplyOne-time temporary fill of at least a one-month supply at retail (multiple fills allowed to total one month if prescription written for less than one month)

LTC incrementsLTC residents receive fills in increments appropriate to the setting, up to a month's supply with multiple fills as necessary during the first 90 days

Emergency supply for LTCOne-time 31-day emergency supply of non-formulary drugs while a formulary exception is being processed

Timing windowAvailable anytime during the first 90 days of the beneficiary's enrollment beginning on the enrollee's effective date, or the first 90 days of the contract year for continuing enrollees

Site of Care — Retail and Long-Term Care Provisions

Billing Rule

Dispense transition supply at retail; LTC fills in appropriate increments

Provide transition fills at retail pharmacies; for long-term care (LTC) residents, supply fills in increments appropriate to the setting (multiple fills as needed up to a month's supply) and provide a one-time 31-day emergency supply of non-formulary drugs while an exception is processed.

Retail: one-time, temporary fill of at least a one-month supply (or multiple fills totaling one month)
LTC: increments up to a month's supply with multiple fills during first 90 days; one-time 31-day emergency supply while exception pending

Definitions

Definition — Non‑formulary and restricted formulary Part D drugs

Not on formularyPart D drugs that are not on the plan's formulary

Formulary with utilization managementPart D drugs on the formulary that require prior authorization or step therapy

Quantity limit below current doseFormulary Part D drugs that have an approved quantity limit lower than the beneficiary's current dose

Background

HealthPartners supports continuity of therapy for Medicare Part D enrollees who face changes in coverage or utilization management that would interrupt ongoing treatment. To accommodate immediate clinical needs, the plan will provide a one-time, temporary supply of non-formulary Part D drugs or formulary drugs that require authorization or step therapy (or have an approved quantity limit lower than the beneficiary's current dose). This temporary fill allows time for the prescriber and enrollee to pursue prior authorization, complete step-therapy requirements, or request a formulary exception so that longer-term coverage arrangements can be established without an interruption in therapy.