Medicare Part D Medication Transition Supply
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Governs one-time transitional supplies of Part D medications for HealthPartners Medicare Part D enrollees (including new, switching, and long-term care residents) to cover immediate needs while prior authorizations, step therapy, or formulary changes are resolved.
No material clinical or coverage changes in this revision.
Coverage Criteria for Transition Supply
inv-01: Eligible enrollees
Covered when ANY of the following enrollee situations apply
Includes 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; continuing enrollees affected by negative formulary changes; 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).
inv-02: Covered drug conditions
Covered when ANY of the following drug conditions apply
Includes Part D drugs not on the formulary; Part D drugs on the formulary that require prior authorization or step therapy; or drugs with an approved quantity limit lower than the beneficiary's current dose (under utilization management).
inv-03: Supply duration and timing
Coverage conditions for the transition fill
supply_limits
- duration_and_amount: At least a one month's supply at retail; if prescription is written for less than a month, multiple fills may be provided to total up to a month of medication.1 month
Retail setting; LTC enrollees may receive incremental fills up to a month's supply with multiple fills as necessary.
- ltc_emergency: Long-term care (LTC) specific provision31 days
One-time 31-day emergency supply for LTC enrollees while an exception is processed.
Transition fills are limited to a one-time temporary supply provided during the first 90 days of the enrollee's coverage or the contract year. Coverage is for a single transition fill of at least a month's supply at the retail setting (or multiple fills totaling a month if the prescription is written for less than a month). Long-term care (LTC) residents may receive multiple incremental fills up to a month's supply as needed, and a one-time 31-day emergency supply is available for LTC while an exception is processed. Requests for fills beyond this one-time transitional supply or submitted outside the 90-day window are not covered under the transition policy.
Provider Actions and Operational Requirements
Temporary one-time supply when utilization management applies
Provide a one-time temporary supply when the drug is non-formulary or subject to utilization management (prior authorization, step therapy, or an approved quantity limit lower than the beneficiary's current dose). Continuation beyond the transition supply requires completion of the applicable utilization management process or a granted exception request.
- Non-formulary includes drugs not on the formulary, drugs on the formulary that require prior authorization or step therapy, or drugs with an approved quantity limit lower than the beneficiary's current dose.
- Continuation of therapy after the transition supply requires completing utilization management (e.g., prior authorization) or submitting and obtaining an exception.
Step therapy: transition supply to allow time to meet requirements
Allow a one-time transition (temporary) fill for drugs subject to step therapy to give the prescriber and enrollee time to meet step requirements or submit an exception request; continuation requires satisfying the step therapy or obtaining an exception.
- Transition fill is provided to permit time to work with the prescriber to switch to a therapeutically equivalent formulary medication or complete an exception request.
- The transition supply is a one-time provision and does not replace the requirement to meet step therapy for ongoing coverage.
Post-fill written notice to enrollee within 3 business days
Send written notice to the enrollee within three business days after the transition fill explaining that the supply is temporary and describing steps to satisfy utilization management or request a formulary exception.
- Notice must explain the temporary nature of the transition supply.
- Notice must include instructions for working with HealthPartners and the prescriber to satisfy utilization management or identify therapeutic alternatives, the right to request a formulary exception, and procedures to request one.
One-time limit and 90-day window for transition fills
Limit transition fills to a one-time temporary supply provided during the first 90 days of enrollment or the contract year; requests beyond the one-time supply or outside the first 90 days are not covered under the transition policy.
- Transition supply is a one-time fill of at least a month's supply at retail (or multiple fills up to a month if prescription written for less).
- For LTC enrollees, increments up to a month's supply with multiple fills are allowed and a one-time 31-day emergency supply is permitted while an exception is processed.
Background and Purpose
The transition policy exists to provide immediate access to necessary medications for enrollees affected by formulary differences, utilization management requirements, plan changes, or changes in level of care. It permits a one-time, temporary fill of at least a month's supply at retail within the first 90 days of enrollment or the contract year so the plan and prescriber have time to either switch the enrollee to a formulary alternative or complete an exception request to maintain the existing therapy. For LTC residents, incremental fills up to a month (and a one-time 31-day emergency supply while an exception is processed) help ensure continuity of therapy during transitions in care.
Key Definitions
Initial Transition Fill Criteria
inv-11: Initial transition fill
Initial transition fill rules
Cost sharing for the transition will not exceed the enrollee's maximum copayment or coinsurance and includes low-income subsidy amounts when applicable.
Step Therapy and Continuation During Transition
| Situation | Policy detail |
|---|---|
| Drugs subject to step therapy during transition | One-time transition fill provided to allow time to satisfy step therapy or request an exception; continuation of therapy requires completing utilization management (e.g., prior authorization or meeting step requirements) or obtaining an exception. |
| Timing for transition step supply | Available anytime during the first 90 days of the enrollee's enrollment or the first 90 days of the contract year for continuing enrollees; limited to a one-time temporary fill to provide time to meet step requirements. |
| Supply amount and setting | One-time temporary fill of at least a one-month supply at retail (or multiple fills up to one month if prescription written for less); LTC may receive incremental fills or a one-time 31‑day emergency supply while an exception is processed. |
| Purpose of transition fill | Allows plan and prescriber time to switch to a therapeutically equivalent formulary medication or to complete an exception request to maintain coverage based on medical necessity. |
| Limitations | Limited to one-time use during the first 90 days; requests beyond the one-time transition fill or outside the 90‑day window are not covered under the transition policy. |
Quantity Limits and Supply Amounts
Site of Dispensing
Transition supply provided at retail (LTC increments allowed)
Transition supply is provided at the retail setting; for enrollees in long‑term care, fills may be provided in increments (multiple fills up to a month's supply) and a one-time 31‑day emergency supply may be provided while an exception is processed.
- Retail: one-time temporary fill of at least a month's supply (or multiple fills to total a month if prescription written for less).
- LTC: incremental fills up to a month and a one-time 31‑day emergency supply during exception processing.
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