CurrentHealthPartnersPolicy N/A

Medicare Part D Medication Transition (One-time Temporary Supply) Coverage Criteria

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Rules for providing one-time, temporary transition supplies of Part D medications to HealthPartners Medicare Part D enrollees, including new enrollees, those switching plans, and residents of long-term care facilities. Applies to coverage and dispensing practices during the first 90 days of enrollment or contract year and to continuing enrollees affected by negative formulary changes.

Policy Summary

PayerHealthPartners

PolicyMedicare Part D Medication Transition — one-time temporary supply rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide a one-time temporary fill of at least a month's supply (31-day emergency supply for LTC) during the first 90 days of enrollment while the prescriber and plan pursue alternatives or an exception.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystransition window

one-timeone-time supply

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CurrentHealthPartnersPolicy N/A

Medicare Part D Medication Transition (One-time Temporary Supply) Coverage Criteria

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Policy Summary

PayerHealthPartners

PolicyMedicare Part D Medication Transition — one-time temporary supply rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystransition window

one-timeone-time supply

Coverage Criteria — Transition Supplies

Eligible enrollees

Covered when ANY of the following enrollee situations apply and during the first 90 days of enrollment (or first 90 days of the contract year for continuing enrollees):

Eligible enrollee situations: New enrollees to HealthPartners Medicare Part D plans as of January 1st following the Annual Election Period; newly eligible Medicare beneficiaries from other coverage; individuals who switch from one plan to another after January 1st; 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.

Transition window: first 90 days from effective date or contract year start.

Supply quantity and setting

Covered when ALL of the following apply for eligible enrollees:

Transition supply rules: Provide a one-time, temporary fill of at least a month’s supply at retail (unless the prescription is written for less, in which case multiple fills may be provided to total up to a month). For enrollees in long-term care (LTC), provide a one-time temporary supply of at least a month’s supply in increments up to a month with multiple fills as necessary. Additionally, provide a one-time 31-day emergency supply of non-formulary drugs for LTC enrollees while an exception is being processed.>= 30 days for retail; 31-day emergency supply for LTC

Timing: anytime during the first 90 days of enrollment or the first 90 days of the contract year for continuing enrollees.

Cost sharing

Cost sharing for the one-time transition will not exceed the enrollee's maximum copayment or coinsurance and includes applicable low-income subsidy amounts; cost sharing is based on the appropriate drug tier (e.g., brand drugs process under the brand copay when appropriate).

Plan will send written notice to the enrollee within three business days of the transition fill.

The policy limits coverage to a one-time, temporary supply. Ongoing coverage of non-formulary Part D drugs requires a completed formulary exception or compliance with applicable utilization management requirements (for example, prior authorization or step therapy). Requests for medication beyond the single transition fill are subject to standard exception and authorization processes and may be denied if not supported by an approved exception or other utilization management approval.

Initial Enrollee Transition Supply

Initial enrollee transition

Initial transition supply when enrolling or switching coverage:

Initial transition: Provide a one-time temporary one-month fill at retail (or shorter fills summing to a month if the prescription is written for less) anytime during the first 90 days of the beneficiary's enrollment beginning on the effective date of coverage.<= 90 days from effective date

Allows time for prescriber and enrollee to pursue therapeutic alternatives or submit an exception request.

Transition Supply for Continuing Enrollees

Transition for continuing enrollees

Continuing enrollees affected by negative formulary changes are eligible for transition supply.

Continuing enrollee transition: Provide one-time, temporary supply during the first 90 days of the contract year to allow transition after negative formulary changes; plan and enrollee should work with the prescriber to switch to a therapeutically equivalent medication on the drug list or complete an exception request to maintain coverage of the non-formulary drug based on medical necessity.

Supports continuity after formulary changes.

Provider Actions & Notifications

Prior Authorization

Temporary supply when PA/step therapy required

One-time temporary supply may be provided for Part D drugs that are non‑formulary or that are on the formulary but require prior authorization, step therapy, or have an approved quantity limit lower than the enrollee’s current dose. This supply is intended to meet immediate needs while the plan and prescriber work to identify a therapeutic alternative or complete a formulary exception request.

Applies to Part D drugs not on the formulary.
Applies to formulary drugs that require prior authorization or step therapy, or have a quantity limit insufficient for the beneficiary's current dose.

Step Therapy

Step therapy exception during transition

Transition fills cover drugs on the formulary that would otherwise be subject to step therapy, providing temporary access so the enrollee can initiate therapy without completing step requirements immediately.

Dispensing Setting and Long-Term Care

Billing Rule

Retail and long‑term care temporary fill rules

Provide a one-time temporary fill of at least a month's supply at retail; enrollees in long‑term care receive supplies in increments up to a month's supply with multiple fills as necessary and a one-time 31‑day emergency supply while an exception is processed.

Retail: one-time fill of at least a 30-day (one‑month) supply, or multiple fills totaling a month if prescription is written for less.
Long-term care: one-time temporary supply in increments up to a month's supply; one-time 31‑day emergency supply during exception processing.

Quantity Limits for Transition Supplies

non-formulary or formulary drugs requiring PA/step therapy — temporary supply

Minimum supply (retail)One-time, temporary supply of at least a month's (≥30 days) supply at retail; multiple fills allowed to total a month if prescription written for less.

Minimum supply (LTC emergency)One-time 31-day emergency supply for long-term care (LTC) enrollees while a formulary exception is processed.

LTC dispensing incrementsLTC enrollees receive a one-time temporary supply in increments up to a month's supply with multiple fills as necessary.

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

PurposeProvides temporary access to allow the plan and prescriber to switch to a therapeutically equivalent formulary medication or to complete a formulary exception request.

Situation	Transition fill available?	Details / limits
Drugs that are on the formulary but require step therapy or prior authorization (or have an approved quantity limit lower than the beneficiary's current dose)	covered	One-time, temporary fill provided to allow access while prescriber and enrollee pursue alternatives or submit an exception; supply is at least a month's supply at retail (or multiple fills totaling a month if prescription written for less); applies during the first 90 days of enrollment or first 90 days of the contract year for continuing enrollees.
Part D drugs that are not on the formulary (non‑formulary)	covered	One-time, temporary supply provided to accommodate immediate needs; at retail a one-month supply (or multiple fills totaling a month if prescription shorter); for LTC enrollees, incremental fills up to a month's supply and a 31‑day emergency supply while an exception is processed.

Definitions & Background

Non-formulary Part D drugs — definition

Definition — not on formularyPart D drugs that are not on the formulary.

Definition — on formulary with UM requirementsPart D drugs that are on the formulary but require prior authorization or step therapy, or have an approved quantity limit lower than the beneficiary's current dose.

Policy actionA one-time, temporary supply will be provided for these non-formulary Part D drugs to accommodate the enrollee's immediate needs while utilization management or exception requests are completed.

This policy is administrative in scope and exists to ensure continuity of therapy when an enrollee changes plans, becomes newly eligible for Medicare Part D, switches coverage, or is affected by formulary changes (including residents entering or residing in long-term care). It permits a one-time temporary supply to avoid treatment interruption while prior authorization, step therapy, or a formulary exception request is pursued.