2026 Transition Policy for iCare Prescription Drug Coverage
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Defines how Independent Care Health Plan (iCare) provides temporary transition supplies of Medicare Part D drugs for new and existing members during plan changes, treatment setting changes, and long-term care placements, and explains member notices, exceptions, and appeals procedures.
No material clinical or coverage changes in this revision.
Transition Supply Coverage Criteria
Transition Supply Criteria
Covered when ALL of the following apply for the specific member scenario
One-time per drug during initial 90-day period; supports multiple partial fills to reach total supply.
Applies when member is new to plan and in long-term care; exceptions/appeals processes available.
Clinical review will assess treatment plan and potential harm from changing regimen.
Used to decide whether transition supply or standard coverage applies.
Transition supply is not available when plan coverage determination between Medicare Part A/B versus Part D is required, when a drug may be ineligible for Part D until the indication is known, or when additional information is needed to confirm safe use. These exceptions mean a temporary transition fill will not be provided until the coverage pathway or safety information is resolved.
Initial Transition Fills for New Members
Initial transition supplies
Initial transition fills for new members
Continuation During Plan / Contract or Setting Transitions
Continuation during Plan/Contract Transitions
Transition across contract years and treatment setting changes
Allows continuity when formulary or rule changes are negative for the member.
Provider Responsibilities and Authorization Rules
Prior authorization required for non-formulary or restricted drugs — transition supply is temporary
If the drug is not on iCare’s approved list or is subject to limits, step therapy, or safety checks, the provider must submit a prior authorization or exception request; a transition supply is temporary while that prior authorization/exception is reviewed.
- Transition supply provided temporarily while PA/exception is reviewed.
- Prior authorization required for drugs not on formulary or those with quantity limits, step therapy, or clinical-safety criteria.
No other prior authorization requirements specified
There are no additional prior authorization requirements stated in the cited sections beyond those applying to non‑formulary, limited, step‑therapy, or safety‑checked drugs.
Step therapy does not block a temporary transition supply
When step therapy applies, providers may obtain a transition supply while the member’s requirement to try a less costly drug or an exception is evaluated; the transition supply is temporary pending completion of step‑therapy review or exception/PA.
- Step‑therapy situations include when the member must try a less costly alternative before the requested drug is approved.
- Transition supply covers short‑term continuity while an exception or PA for step therapy is pursued.
No additional step therapy requirements specified
No step therapy requirements beyond the general statement that step therapy may apply are specified in these chunks.
Submit clinical documentation or letter of medical necessity for exceptions/PA
To request an exception or support prior authorization, the provider must submit clinical information or a letter of medical necessity explaining why covered alternatives would not work or would harm the member; iCare generally decides within 72 hours, or 24 hours for expedited (urgent) requests.
- Letter must state the drug is needed because covered drugs would not work or would harm the member.
- iCare must notify decision within 72 hours for standard requests and within 24 hours for expedited requests.
Reference online notice for auxiliary aids and language services
Providers may refer to iCare’s online Notice of Availability for auxiliary aids and services; free language assistance, auxiliary aids, and alternate format services are available at 1‑800‑777‑4376 (TTY: 711) and the notice is posted at www.icarehealthplan.org.
- Call 1‑800‑777‑4376 (TTY: 711) for language or auxiliary aid services.
- Notice available at www.icarehealthplan.org.
Conditions that can lead to denial of a transition supply
Transition supply may be denied if the drug cannot be covered as a Part D drug (e.g., needs Part A/B vs Part D determination or may be ineligible for Part D), if it is not on iCare’s approved list, or if required clinical information to confirm safe use or coverage is not provided.
- Denial triggers include drugs requiring Part A/B versus Part D coverage determination or drugs potentially ineligible for Part D.
- Denial may occur when clinical information needed to determine safe use or coverage is missing.
No additional denial triggers specified in these chunks
The cited auxiliary‑aid notice chunks do not list any separate denial triggers beyond the coverage and clinical‑information conditions already specified elsewhere.
Step Therapy and Exception Process
| Situation | Policy statement |
|---|---|
| Step therapy applies (member required to try a less costly drug first) | |
| If step therapy applies, iCare may provide a temporary transition supply while the step therapy requirement is evaluated or while the member/ provider pursues an exception or prior authorization. |
Quantity Limits for Transition Supplies
Where Transition Supplies Are Obtained
Transition supply at pharmacy after changing treatment settings
When drugs are obtained at a pharmacy after a change in treatment setting (for example hospital↔home, skilled nursing facility transfers, or shifts affecting Part A/B vs Part D coverage), iCare will cover up to a 31‑day transition supply at the pharmacy.
- If the member changes treatment settings more than once in the same month, an exception or prior authorization may be required.
- iCare will review treatment plans to determine whether changing the regimen would harm the member.
Definitions and Member Services
Background and Policy Scope
The purpose of a transition supply is to maintain continuity of therapy while iCare reviews coverage, prior authorization, or exception requests that could otherwise interrupt a member’s medication at enrollment or during plan changes. When a drug is not on the plan’s approved list or requires additional review for limits, step therapy, or clinical information, iCare will provide a temporary supply so the member can continue therapy while the determination is made.
Transition supplies apply for several member situations: for new members during the initial enrollment period, for members moving between treatment settings (for example hospital to home or skilled nursing transfers), and for members affected by contract-year formulary changes. Standard transition fills are time-limited and intended only to bridge therapy until formal coverage or authorization decisions are completed.
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