Neighborhood Health RI transition fill policy update

Transition Fill (TF) Coverage Logic

Eligibility for Transition Fill (TF)

Transition fills are allowed when ANY of the following beneficiary scenarios apply:

ANY of the following

New Beneficiaries enrolled following the annual coordinated election period
Newly eligible Medicare Beneficiaries from other coverage
Beneficiaries who switch from another Part D plan after the start of a Contract Year
Current Beneficiaries affected by negative formulary changes across Contract Years (including new UM requirements)
Beneficiaries residing in long-term care (LTC) facilities, including those admitted to or discharged from an LTC facility

What qualifies as Non-formulary / TF-eligible drug

A drug will be considered Non-formulary and potentially eligible for TF when ANY of the following apply:

ANY of the following

Part D drugs not on the Sponsor's formulary
Part D drugs previously approved via an exception once the exception expires (note: CMS guidance discourages including expiring exceptions unless required)
Formulary drugs that require prior authorization, step therapy, or have approved quantity limits lower than the beneficiary's current dose under Sponsor utilization management rules

Transition supply quantity & timing rules (Non-LTC)

For non-LTC beneficiaries, TF is available under the following ALL conditions:

ALL of the following

One-time temporary fill of at least the applicable month's supply
Sponsor determines applicable month supply; 2026 Sponsor default = 30-day supply
TF available anytime during the first 90 days of beneficiary's enrollment, beginning on the effective date
If prescription written for less than a month's supply, multiple fills are allowed up to the applicable month's total

Transition supply quantity & timing rules (LTC)

For LTC beneficiaries, TF is provided when ALL of the following are met:

ALL of the following

One-time temporary fill of at least the applicable month's supply consistent with LTC dispensing increment
2026 Sponsor default = 31-day cumulative supply; oral brand solids limited to 14-day fills unless SCC 21-36 provided
Multiple fills allowed to provide up to a total of the applicable month's supply during the first 90 days of enrollment
After transition period expiry or exhaustion of TF supply, at least a 31-day emergency supply is provided while exception/PA pending (unless written for shorter)
Early refill edits not to be used to limit access upon LTC admission/discharge

TF for renewing beneficiaries and cross-contract-year cases

Transition fills are allowed when ALL of the following apply:

ALL of the following

Renewing beneficiaries impacted by negative formulary changes during the TF Window
Beneficiaries must have a history of utilization of the drug requested (look-back applied at GPI-10 level; Sponsor look-back 180 days noted)
TF logic applies across contract years for enrollments beginning Nov 1 or Dec 1 when access to transition supply is needed

Multi-Ingredient Compound (MIC) TF logic

Adjudication of MICs follows this decision flow:

ALL of the following

If Part D eligible MIC
- Determine if MIC contains any Part A/B ingredients; if so, MIC may not be Part D eligible
- Formulary status may be based on most expensive Part D ingredient or entire claim depending on plan setup
- If most expensive ingredient is Non-formulary and TF-eligible → entire MIC pays as TF and receives exception-tier cost share
- If most expensive ingredient is formulary → MIC pays at contracted rates

Utilization management edits and TF ineligible edits

Certain edits are NOT TF-eligible (i.e., TF overrides will not be applied) — these are coded to reject:

ANY of the following

Drugs excluded from Part D benefit (per PBM drug database)
Drugs requiring Part A vs Part D coverage determination
DUR safety edits such as therapeutic duplication, cumulative acetaminophen, MME limits, drug interactions, and age alerts

General TF Eligibility / Processing

Claims will be processed as Transition Fills when TF program logic identifies eligibility and applicable edits are overridden. TF is applied when ALL of the following occur:

ALL of the following

Beneficiary is within the TF window (e.g., new to plan, renewing within defined window, or other TF scenarios identified by Sponsor)
Submitted claim would otherwise reject due to formulary change, non-formulary status, prior authorization requirement, step therapy, quantity limits (QvT), maximum daily dose (DD), or age edits — and is eligible per Sponsor design
Drug is not excluded from TF (see excluded drugs / Part A/B only drugs)

Overrides & Manual TF

Manual TF overrides may be entered by Delegated PBM when ANY of these conditions apply:

ANY of the following

Non-LTC beneficiary moves between treatment settings and adjudication did not auto-identify the change
Dosage increase during transition requires TF
Beneficiary requested an exception and decision is pending at TF period expiration or TF cumulative supply exhausted
Other case-by-case scenarios where POS automation did not capture TF eligibility

TF Supply & Time Parameters (summary)

TF supply/time allowances vary by beneficiary type and Sponsor plan design. Apply ALL applicable limits:

ALL of the following

Non-LTC new/renewing beneficiaries: cumulative 30-day supply within first 90 days in plan (multiple fills allowed to reach cumulative supply)
LTC beneficiaries: cumulative 31-day supply within first 90 days in plan; oral brand solids limited to 14 days' supply unless SCC 21-36 submitted or CMS exceptions apply
LTC Emergency Supply (ES): cumulative 31-day supply (oral brand solids limited to 14 days) allowed when TF parameters exhausted and a coverage decision is pending; limited to one ES per rolling 30-day lookback per beneficiary/pharmacy/plan
Sponsor plan design may allow greater supplies; always limited by amount prescribed

Rejected/Excluded Scenarios (Not TF eligible)

Claims are NOT processed as TF when ANY of the following apply:

ANY of the following

Drug is a Medicare Part A or B only product (Med A/B only drugs are excluded from TF and are tagged with 'N' in Med D status)
Drug is explicitly excluded by CMS from Part D coverage
Automated TF logic does not allow override of Refill Too Soon (RTS) edits for new and renewing beneficiaries, except for LTC Level of Care Change
DUR safety edits configured to reject at point of sale are not overridden by TF

Step Therapy and Type 2 ST-PA handling

TF processing for step therapy follows Type 2 ST-PA rules and Sponsor configuration:

ALL of the following

If step therapy is Type 2 (new starts only) and history shows beneficiary met the step (per 108-day lookback), step TF may not be required
If beneficiary already meets step requirements via historical use, TF may override step therapy rejects and allow continuation fills; Step TF letters may not be generated in such cases

Quantity Limits (QvT) and Daily Dose (DD)

Apply TF overrides in the following order and conditions:

ALL of the following

TF will override QvT and DD rejects when within TF window per Sponsor design
QvT (quantity over time) TF (reject 76) takes precedence over DD TF when both are present
If current QL is lower than member history QL, the QL edit is overridden and TF processing applies

Age Edits and Unbreakable Pre-Packaged Drugs

Special handling rules for age edits and packaging:

ALL of the following

Age edits for safety may be overridden by TF (reject 76)
Unbreakable pre-packaged medications: if single package quantity meets required TF cumulative supply (even if exceeds maximum benefit), TF may pay; if current fill quantity exceeds single package quantity, pharmacy will be messaged to resubmit for a single package

Renewing Beneficiaries & Negative Formulary Changes

Renewing beneficiaries with history may be eligible for TF when ALL of the following are true:

ALL of the following

Beneficiary has history of utilization (GPI level 10 match) of impacted drug during history lookback (e.g., 180 days referenced for some checks)
Drug experienced a negative formulary change compared to historical edits
No active clinical authorization already exists on the beneficiary record to override TF-eligible edits

NCPDP / SCC / Reject Codes Referenced

Administrative / POS standards referencedmixed

NCPDP D.0	NCPDP Telecommunication Claim Standards version referenced for POS messaging
SCC 21-36	Submission Clarification Codes used to indicate LTC dispensing increments for longer fills

NCPDP / Reject codes referencedmixed

R70	Non‑formulary (Plan reject 70)
R75	Prior Authorization required (reject 75)
R76 / 76	Quantity limit / other plan limit rejects overridden by TF (reject 76 referenced)
R79	Refill Too Soon (RTS) reject (79)
R88	DUR reject (88)
A3	Product covered under Hospice Medicare A (Part A/B vs D messaging)
A4	Product covered under Medicare bundled payment to ESRD dialysis facility
A5	Not covered under Part D law
A6	Product/service covered under Medicare Part B
AG	Days supply limitation reject messaging (AG) - 'Resubmit for Remaining Supply of XX'

SCC / Submission Clarification Codes referencedmixed

SCC 21-36	Used to permit exceptions for oral brand solids in LTC beyond 14 days per CMS guidance
SCC 420-DK	Submission Clarification Code used with value *18 to indicate Patient Location Code identified as LTC for LTC LOC processing
SCC 420-DK	Submission Clarification Code used with value *7 to indicate LTC Emergency Supply POS submission

Actions Required by Providers, Pharmacies, and PBM

Prior Authorization

Medical review and exception/authorization process

Delegated PBM will make authorization and exception request forms available to beneficiaries and prescribers by mail, fax, email, and via plan websites; providers and prescribers must use these forms to submit exception requests or prior authorizations when a transition fill is temporary and continued coverage is needed.

Documentation Required

Transition notice and communication requirements

For Delegated PBM‑fulfilled transition fills, pharmacies and the PBM must send a written TF notice to the beneficiary within three (3) business days after adjudication of a temporary transition fill; for LTC oral brand solids limited to 14‑day fills, the written notice is sent within 3 business days after adjudication of the first temporary fill. Pharmacies should expect POS messaging indicating TF status and counsel beneficiaries about the temporary nature of the supply and next steps.

Numeric Limits and Lookbacks for TF Processing

Key TF Thresholds

TF Window90 days from beneficiary's enrollment effective date

Non-LTC cumulative TF supply30 days (Sponsor default 2026)

LTC cumulative TF supply31 days (oral brand solids limited to 14 days unless SCC 21-36)

Beneficiary TF notice timingWithin 3 business days after adjudication of a temporary transition fill

Renewing beneficiary look-back180 days (GPI-10 level history look-back)

LTC Emergency Supply frequencyLimited to one ES per rolling 30-day lookback per beneficiary/pharmacy/plan

History lookback for Type 2 ST-PA

Policy Background and Purpose

This Delegated PBM policy operationalizes Centers for Medicare & Medicaid Services (CMS) Part D transition fill (TF) requirements to ensure continuity of therapy when beneficiaries gain new coverage, experience negative formulary changes, or undergo level-of-care changes such as admission to or discharge from a long-term care (LTC) facility. The Delegated PBM implements adjudication logic at the point of sale (POS) that automatically identifies TF-eligible claims and applies TF program rules consistent with Sponsor plan design and CMS guidance, allowing a temporary supply while coverage, prior authorization, or exception requests are resolved. [[3],[7],[18],[22]]

Defined Terms

Definitions

Delegated PBMThe pharmacy benefit manager contracted to implement and operate the Sponsor's transition fill processes and adjudication.

Transition Fill (TF)A temporary supply of a Part D covered drug provided per CMS Part D requirements to avoid interruption in therapy while coverage/exception issues are resolved.

Applicable Month's SupplyThe CMS-required transition supply minimum for the plan year as submitted to CMS (Sponsor 2026 default: 30 days non-LTC, 31 days LTC).

LICS III / LISLow Income Cost Sharing subsidy levels; TF claims for LICS III beneficiaries are processed according to beneficiary's LICS level.

SCC 21-36Submission Clarification Codes indicating LTC dispensing increments permitting longer fills for LTC residents.

GPI-14 / GPI-10Generic Product Identifier hierarchical codes used to accumulate cumulative TF days' supply and to evaluate history/look-back.

Policy Update Changes

2025-06-01clarifiedLatest

Added missing definition for NDC and updated Regulatory Citations/References formatting.

OpenPayer

2026 Transition Fill Policy

Transition Fill (TF) Coverage Logic

NCPDP / SCC / Reject Codes Referenced

Actions Required by Providers, Pharmacies, and PBM

Numeric Limits and Lookbacks for TF Processing

Policy Background and Purpose

Defined Terms

Policy Update Changes