Formulary Transition (Transition Policy for Medicare Part D)
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Defines Nascentia Health Plus's process for providing temporary access to Part D drugs when a member's current therapy is not covered or is subject to utilization management, applicable to new and existing Medicare and Medicare-Medicaid Plan (MMP) members including LTC residents and enrollees affected by formulary changes.
No material clinical or coverage changes in this revision.
Transition and Coverage Criteria
Transition coverage criteria
Covered when ALL of the following are met for transition eligibility
Source: policy transition population list
Defines Non-formulary Drugs
MedImpact/CMS minimum transition period
POS temporary supply processing handled by PBM/MedImpact
Outpatient Temporary Fill
Outpatient (retail) new member temporary fill
If brand is filled under transition, prior claim must also be brand; if generic, prior claim may be brand or generic (NSDE marketing status).
LTC Temporary Fill
Long-term care (LTC) new member temporary fill
Complies with LTC dispensing increments and emergency supply rules.
Across-Contract-Year Transition
Transition across contract years
Negative changes include removal, tier downgrade, or added utilization management
Protected-Class Continuation
Protected classes
Six classes listed per CMS guidance
Transition Extension
Transition extension
Case-by-case determination
Initial transition eligibility and period
Covered transition situations and timing
CMS-aligned list of eligible populations
Plan may extend transition beyond minimum
Temporary fills and emergency supplies
Temporary fill rules by site of care
Retail POS temporary fill rules
LTC dispensing and emergency supply rules
SCC '18' triggers automated transition handling
Point-of-sale edit and override rules
Adjudication edits applicable during transition
Limited POS edits per MedImpact implementation statement
Automatic and manual POS override procedures
SCC '18' support for LTC claims
Extensions and cost-sharing
Cost-sharing and transition extension
Case-by-case extension and POS override capability
Aligned with CMS statutory requirements
Drugs that are excluded from Medicare Part D by statute are not eligible for the transition process and therefore cannot be dispensed as transition supplies under this policy. This includes any drug the statute expressly excludes from Part D coverage. However, if Nascentia Health Plus elects to cover an otherwise excluded drug under an Enhanced or MMP benefit, that drug will be treated as a Part D drug for transition purposes and may be eligible for transition handling consistent with the remainder of this policy.
Drugs statutorily excluded from Part D remain ineligible for transition fills unless Nascentia Health Plus covers them under an Enhanced or MMP benefit; in that case they are handled the same as Part D drugs for transition. When a transition fill is adjudicated, Nascentia Health Plus must mail a written transition notice to the enrollee within 3 business days of adjudication that explains the temporary nature of the supply, how to work with the plan and prescriber to satisfy utilization management requirements or identify formulary alternatives, the enrollee's right to request a formulary exception, and procedures to request one. For LTC residents dispensed multiple supplies in increments of 14 days or less, the notice must be provided within 3 business days after adjudication of the first temporary fill.
The policy reiterates that any drug excluded from Part D under Medicare statute is not eligible for transition fills, with the exception that Nascentia Health Plus may treat such drugs as Part D for transition if they are covered under an Enhanced benefit. This alternate wording emphasizes that statutory exclusions are binding unless the plan specifically includes the drug in an Enhanced or MMP benefit, in which case normal transition rules apply.
In the long-term care (LTC) setting, transition supplies must follow LTC dispensing practices and notification requirements: when multiple supplies of a Part D drug are dispensed in increments of 14 days or less, Nascentia Health Plus must provide the written transition notice within 3 business days after adjudication of the first temporary fill. LTC residents may receive transition supplies consistent with the LTC provisions of this policy (including admission/readmission handling) and notices must be produced per the CMS-aligned timing specified above.
Codes, Timing and Reporting
| 42 CFR §423.120(b)(3) | CMS regulation referenced for transition process requirements |
| 42 CFR §423.153(b) | POS PA edits to determine Part A/B vs Part D and excluded coverage example |
| NCPDP SCC 18 | Submission Clarification Code indicating new dispensing due to LTC admission/readmission |
Prescriber and Pharmacy Responsibilities
Resolve PA and step-therapy edits at point-of-sale
Step therapy and prior authorization edits are applied but must be resolvable at the point-of-sale; MedImpact/plan systems provide POS messaging and coding so pharmacies can process temporary transition fills immediately while the exception/PA process proceeds.
- POS edits for PA and step therapy are coded to require resolution at POS.
- MedImpact provides POS messaging per NCPDP standards to support resolution.
Allow temporary fill while PA/exception pending
One-time temporary fills are allowed at POS for non-formulary or UM-restricted Part D drugs during the member's transition period while a prior authorization or exception is being requested.
- Outpatient (retail): one-time temporary fill of at least a month's supply during first 90 days of enrollment (or multiple fills up to one month if Rx written for less).
- LTC: one-time temporary supply of at least a month's supply dispensed incrementally during first 90 days; after transition expiry a 31-day emergency supply may be provided while PA/exception pending.
Extend transition and use POS overrides if PA/exception unresolved
If an exception or appeal remains unresolved at the end of the minimum transition period, Nascentia Health Plus may extend the transition and apply POS overrides on a case-by-case basis to continue coverage until a transition (switch or decision) is made.
- Plan or MedImpact can enter POS overrides if authorized to maintain coverage during extension.
- Extension continues until exception/appeal is decided or member is transitioned to an alternative.
Make PA/exception forms and POS support available
Prior authorization and exceptions request forms will be made available to enrollees and prescribers via mail, fax, email, and on plan websites; pharmacies may contact the PBM Pharmacy Help Desk for POS override assistance.
- Forms and instructions available upon request to members and prescribing physicians.
- Pharmacies can contact MedImpact Pharmacy Help Desk for immediate POS override assistance.
Allow POS resolution or override of step therapy during transition
Step therapy edits are coded to be resolved at point-of-sale and may be overridden during the member's transition period per MedImpact POS processes to allow temporary access.
- During transition, only limited POS edits are applied; other UM edits may be automatically overridden.
- Pharmacies may request manual POS overrides for emergency fills via the PBM help desk.
Do not apply UM to transitioning members on protected-class drugs
Utilization management restrictions (PA and/or step therapy) are not applied to transitioning members who are already taking drugs within the six CMS ‘classes of clinical concern’ during the transition period.
- Six classes: antidepressant, antipsychotic, anticonvulsant, antineoplastic, antiretroviral, immunosuppressant.
- Continued coverage for duration of treatment without UM restrictions for transitioning members on these agents.
Protected-class step-therapy protections and 120-day transition
For new members on protected-class drugs, protected-class logic overrides transition logic and a 120-day transition period from member start date is provided; UM protections ensure continued access without PA/step therapy.
- Protected-class override processes take precedence at POS for new members.
- New members receive a 120-day transition for protected-class therapies.
P&T committee reviews and recommends step therapy/PA policies
MedImpact’s Pharmacy & Therapeutics (P&T) committee reviews and recommends step therapy and prior authorization guidelines; the P&T role also includes review of procedures for medical review of non-formulary requests and the exception process.
- P&T reviews clinical considerations for step therapy and PA rules.
- P&T recommends procedures for medical review and exception adjudication.
Provide transition notice files, prescriber templates, and mailing support
MedImpact will provide transition notification files and prescriber letter templates; Nascentia Health Plus may use MedImpact’s print vendor or mail notices on its own to notify prescribers and members.
- Transition Notification 'All' and 'Print' files are provided via FTP daily to support member/prescriber notices.
- Prescriber Transition Notification template and file specification are available to assist mailings.
Use NCPDP SCC '18' for LTC admission/readmission transition claims
For LTC admission or readmission emergency fills, pharmacies must submit NCPDP Submission Clarification Code '18' on the claim to trigger transition recognition and limited POS edits; MedImpact will recognize SCC '18' and apply transition handling without a manual override.
- SCC '18' indicates new dispensing due to admission/readmission and prompts automatic POS transition handling.
- If needed, manual POS override is also an option for emergency fills.
Mail enrollee written notice within 3 business days after adjudication
Nascentia Health Plus must send a written notice via U.S. first-class mail to the enrollee within three business days after adjudication of the temporary transition fill; notices must explain the temporary nature, instructions for addressing UM, right to request a formulary exception, and exception request procedures.
- If the transition supply is dispensed in multiple fills, send notice with the first transition fill (special timing for LTC increments applies).
- Long-term care residents dispensed multiple supplies in ≤14-day increments must receive the notice within 3 business days after adjudication of the first temporary fill.
Prescriber notification file and template provided for mailing
MedImpact provides a Prescriber Transition Notification file containing prescriber and member information and transition claim details; Nascentia Health Plus may use MedImpact’s template and vendor to mail prescriber letters.
- File includes prescriber info, member info, and transition claim details.
- Plan may use MedImpact's print vendor or mail on its own using the provided template/specification.
Risk of POS denial for non‑Part D or excluded drugs
Claims may be denied at POS if edits determine the drug is excluded from Part D, is a non-Part D drug, or is not a Part D medically accepted indication; these exclusions are applied during transition.
- POS PA edits per 42 CFR §423.153(b) identify drugs excluded from Part D or more appropriate under Part A/B.
- Excluded drugs by statute are not eligible for transition unless covered under an Enhanced benefit and treated as Part D for transition.
POS requires prior‑year approved claim (HICL match) for across‑year transition
For transition across contract years, POS auto-transition requires an approved prior-year claim with the same HICL value (and matching brand/generic status for brands) in the prior calendar year; absence of such claim may prevent POS recognition of across-year transition.
- POS looks for approved claims prior to January 1 with the same HICL value to allow transition at the start of the new contract year.
- Brand fills under transition require prior claim also be brand per NSDE marketing status; generics may match brand or generic.
Complete POS resolution; Part A/B, non‑Part D, and safety edits still apply
All required POS resolution for transition must be completed at adjudication; edits that determine Part A/B vs Part D, non‑Part D exclusions, and safety edits remain applied and cannot be overridden.
- During transition, edits to determine Part A/B coverage, prevent coverage of non‑Part D drugs, and safety utilization edits are retained at POS.
- Other non-formulary related edits are automatically overridden at POS during the transition period.
Report transition fills on the PDE as covered Part D drugs (PDE reporting required)
Transition fills that qualify under the policy must be reported to CMS as covered Part D drugs on the Prescription Drug Event (PDE) with appropriate plan and member cost‑sharing; failure to report correctly could lead to CMS reporting issues and potential recoupment during reconciliation.
- Report transition fills on the PDE as covered Part D drugs with correct plan and member cost‑sharing.
- Incorrect PDE reporting creates risk of CMS reconciliation problems, denials, or recoupment.
Policy Background
The transition process exists to ensure continuity of therapy for enrollees whose current medications are not covered by their new plan's formulary or are subject to utilization management. It applies to new enrollees after the coordinated election period, newly eligible Medicare beneficiaries, members who switch plans after the contract year begins, current enrollees affected by negative formulary changes, and residents of long-term care facilities. Where permitted by the plan (for example, drugs covered under an Enhanced or MMP benefit), excluded drugs may be treated as Part D for transition so that clinically necessary therapy is maintained.
Key Terms and Definitions
Continuation for Protected-Class Therapies
Protected-Class Continuation criteria group
Continuation for protected-class therapies
Protected-class continuation and override rules per CMS guidance
Step Therapy Rules and Overrides
| Coverage edit | Policy summary |
|---|---|
| Step therapy edits | Step therapy edits are coded to be resolved at point-of-sale and may be overridden during the member's transition period; step therapy must be resolved at POS per MedImpact adjudication capabilities. |
| Coverage label | Policy summary |
|---|---|
| Protected-class transitioning members | Utilization management restrictions (PA and/or step therapy) are not applied to transitioning members who are already taking drugs within the six CMS protected classes; continued coverage is granted for duration of treatment while drug remains on formulary. |
| Protection | Policy details |
|---|---|
| Six classes of clinical concern | The six classes are antidepressant, antipsychotic, anticonvulsant, antineoplastic, antiretroviral, and immunosuppressant. For members transitioning on agents in these classes, protected-class logic overrides transition logic; new members receive a 120-day transition period and UM (PA/step therapy) is not applied. |
Temporary Supply and Emergency Fill Quantities
Settings and Site-Specific Transition Rules
Site‑specific temporary fill rules for non‑retail settings
Home, infusion center, hospital outpatient and office settings follow transition POS rules: retail one‑time temporary fills of at least one month's supply during first 90 days; LTC and facility settings follow LTC-specific dispensing increments and emergency supply rules.
Retail: one‑time temporary fill during first 90 days
In retail outpatient settings, provide a one‑time temporary fill of at least a one‑month supply (or multiple fills up to one month if prescribed for less) anytime during the first 90 days of enrollment to cover non‑formulary Part D drugs under transition.
Infusion/LTC admission/readmission: SCC '18' triggers transition handling
When an LTC admission/readmission triggers transition handling, pharmacies should submit SCC '18' on the claim; MedImpact's adjudication will recognize eligibility for transition supplies and apply only the limited POS edits without needing a manual override.
Retail and LTC one‑time temporary fill rules (summary)
Summary: Retail and long‑term care sites permit a one‑time temporary fill of at least a month's supply during the first 90 days; LTC allows incremental dispensing per regulation with a 31‑day emergency supply after transition while exception/PA pending.
- Retail: one‑time ≥ one month's supply during first 90 days
- LTC: one‑time ≥ one month's supply dispensed incrementally during first 90 days
- After transition in LTC: 31‑day emergency supply while PA/exception pending
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