CurrentNeighborhood Health Plan of Rhode IslandPolicy 000988

2026 Transition Fill Policy

Governance of Medicare Part D transition fills (temporary supplies) for Neighborhood Health Plan of Rhode Island via a Delegated PBM; applies to plan operations and providers/pharmacies processing transition fills.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policy2026 Transition Fill Policy

Policy CodePolicy 000988

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateJun 1, 2026

Key ActionDelegated PBM will auto-pay eligible transition-fill claims at point of sale and send a transition notice to the beneficiary within 3 business days after adjudication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Non-LTC day supply

31LTC cumulative day supply

90TF Window (days)

3 bdNotice timeframe

14Oral brand solids limit (LTC)

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120LTC look-back (days)

Transition Fill Coverage Criteria

Initial Transition Fill Coverage

Covered when ALL of the following are met for a Beneficiary in scope:

Eligibility and timing: Beneficiary is within the TF Window (first 90 days of enrollment beginning on effective date) and belongs to eligible groups: new to plan after coordinated election period, newly eligible Medicare beneficiaries from other coverage, switched plans after Contract Year start, affected by negative formulary changes, or residing in LTC (including admission/discharge).within first 90 days

Delegated PBM implements TF per Sponsor benefit design and CMS guidance.

Drug status: Drug is a Part D drug that is non-formulary, subject to prior authorization or step therapy, or has quantity limits lower than beneficiary's current dose, or is a formulary drug with utilization management edits preventing immediate access.

Biosimilars are handled as non-interchangeable brand/generic for TF.

Adjudication and supply limits: Delegated PBM adjudication system automatically processes and pays transition-eligible claims at POS; non-LTC up to a 30-day cumulative supply (or less if prescribed); LTC up to a 31-day cumulative supply with oral brand solids limited to 14-day fills unless SCC 21-36 are used; multiple fills allowed to reach cumulative supply when prescriptions are written for less than a month's supply.30 days non-LTC; 31 days LTC; 14 days oral brand solids without SCC

POS messaging follows NCPDP standards and pharmacies are not required to submit PAMC for TF-paid claims.

Cost sharing: Cost-sharing for transition supply follows Sponsor plan design; LIS beneficiaries' cost sharing will not exceed statutory maximums; non-LIS beneficiaries pay cost share consistent with non-formulary exceptions or applicable UM criteria being met.

Delegated PBM applies Sponsor cost-sharing setup for TF claims.

Notices & follow-up: Delegated PBM will send a written transition notice to the beneficiary within 3 business days after adjudication, including information on the temporary nature of the fill and instructions to work with prescriber/plan and how to request a formulary exception or PA.within 3 business days

TF Claim and Letter Tags drive daily TF Letter File extraction and letter generation.

Transition Extensions and Cross-Year Coverage

Extension and year-crossing rules:

Transition extension: Delegated PBM will provide extension of the transition period on a case-by-case basis while exception requests or appeals remain pending; Sponsor allows a 30-day supply for transition extension in 2026.30 days extension allowed

Requests processed via Pharmacy Help Desk or Customer Care per Sponsor instructions.

Contract year carryover: Transition policy extends across Contract Years for beneficiaries enrolling effective Nov 1 or Dec 1 to provide necessary transition supply until switch or exception decision is made.

TF Window may span Contract Years when enrollment dates fall in Nov/Dec.

General TF eligibility

Covered when TF eligibility and timing rules are met

TF eligibility categories

Modes of processing: Auto POS adjudication OR manual override via Pharmacy Help Desk/Customer Care when auto-identification not available.
Manual overrides tagged with PAMC and return same messaging.
Drug eligibility: Drug must be identified as Part D eligible (Med D field 'Y') and not a Non-Med D ('N'). Multi-ingredient compounds processed per plan-specific MIC rules.
Certain Part A/B drugs and Part D exclusions are not TF-eligible.

LTC Transition Fill

LTC-specific coverage rules

LTC TF supply rules: LTC transition fills allowed up to cumulative 31 days' supply; oral brand solids limited to 14 days unless SCC 21-36 or CMS exceptions; multiple fills allowed to reach cumulative supply; LTC Emergency Supply allowed when TF window exhausted and exception pending.31 days / 14-day oral brand solids

SCC 21-36 used to indicate LTC dispensing days' supply and LTC ES is allowed per rolling 30 days.

Level of Care Change

Level-of-care change coverage rules

Level of Care Change: For non-LTC residents with adjudication indicating a LOC change from LTC to non-LTC, TF may be auto-provided at POS for claims rejecting Refill Too Soon (79) or DUR (88); otherwise pharmacy may request override via Pharmacy Help Desk. Identification uses matching GPI 14 claim within 120-day history with LTC Patient Location Code.120-day lookback / 30-day cumulative supply for non-LTC LOC change

Non-LTC LOC change allows up to cumulative 30-day supply (or greater per benefit design).

TF Eligible Conditions

Covered when the claim meets TF conditions for the specific edit type and plan benefit design allows TF:

TF Edit Types: TF processing applies to Non-formulary drugs, Formulary drugs with prior authorization, step therapy, quantity limits (QvT/DD), and age edits; applicability may vary by Sponsor benefit design.

Order of processing: step therapy; Prior Authorization; Quantity Limits (including daily dose and age).

LTC Level of Care Change TF: Beneficiary admitted to LTC within past 30 days or discharged; identified via Patient Location Code/PLC and SCC values at POS; allows cumulative days supply per LTC LOC benefit and can override RTS (79) and DUR (88) at POS when set up to do so.120-day claim history on GPI 14 to detect LTC

POS submissions should include SCC 420-DK value '18' and LTC PLC; automated and manual overrides available if drug qualifies as TF.

LTC Emergency Supply (ES): Allowed when TF parameters are exhausted, exceeded or expired and a coverage determination or exception is pending; cumulative 31-day supply (oral brand solids limited to 14 days unless SCC 21-36), one ES per LTC stay, one ES per rolling 30 days.

TF eligibility, overrides, and operational rules

Transition Fill (TF) will pay under specified conditions and may override certain edits; specific rules and exceptions follow.

General TF availability: TF is available for formulary drugs with Age Edits that override a reject 76; TF processing applies to TF-eligible edits unless overridden by beneficiary-level clinical prior authorization or specific logic selected by the Sponsor.

Beneficiary-level clinical PAs will prevent TF processing when present.

AG (days supply) handling: Claims exceeding remaining allowed TF cumulative days supply return an AG reject and should be resubmitted for the remaining allowed days; reducing days supply and resubmitting allows TF processing.

AG message: 'Resubmit for Remaining Day Supply of XX'.

Unbreakable pre-packaged medication: If manufactured packaging cannot be split, pre-packaged medication days supply may be dispensed even if it exceeds maximum benefit provided cumulative DS prior to current fill is less than required benefit and the cumulative including current fill is <= single package quantity; if current fill exceeds single package quantity, pharmacy is messaged to resubmit for a single package.

Delegated PBM will not apply its transition policy to expiring formulary exceptions unless and until CMS issues guidance requiring otherwise. This means that when a beneficiary’s coverage is based solely on a time-limited exception that is expiring, the Delegated PBM will not extend transition-fill protections for that expiring exception absent explicit CMS direction.

Drugs identified as Non-Med D on the Delegated PBM drug database (marked with an 'N' in the Med D field) are excluded from Transition Fill (TF) processing and will not be considered for TF adjudication at point-of-sale.

Drugs that require coverage under Medicare Part A or Part B, and drugs that are excluded from the Part D benefit, are coded to reject and are not eligible for Transition Fill. Part A/B-only drugs are tagged as 'N' in the Med D field and will be rejected per NCPDP standards; drugs excluded from Part D require medical documentation of a medically accepted indication before they can be considered for Part D coverage.

TF override logic is not applied to drugs with dose limits based on maximum FDA labeling, to drugs determined to be Part A or Part B only, or to drugs not covered by CMS under the Part D program (including those that require a medically accepted indication). Such claims are not eligible for TF overrides at POS or via manual override processes.

When a beneficiary-level clinical prior authorization has been entered to override all TF-eligible edits on the beneficiary record, TF processing does not apply. Under this condition, claims will not process as TF and TF-related letters will not be generated or sent.

Claims that trigger DUR safety edits (for example therapeutic duplication, cumulative acetaminophen, MME limits, drug–drug interactions, and age alerts) are set to reject and are not bypassed by TF processing. Such DUR safety rejects remain non-payable under TF rules unless other, specific override criteria are met.

Drugs excluded from Part D that require a medically accepted indication will be denied in the absence of documentation demonstrating the medically accepted indication. Beneficiaries may request a formulary exception and have the right to appeal denials, but excluded drugs are not covered under Part D unless the medically accepted indication is documented and coverage determination criteria are met.

Coding, POS, and Reject Codes

LTC Dispensing Codesmixed

SCC 21-36

Submission Clarification Codes indicating LTC dispensing of varying days' supply; allows oral brand solids exceptions to 14-day limit.

TF Approved Message Codesmixed

005	TF claim is paid during transition period but required a prior authorization.
006	TF claim is paid during transition period and was considered non-formulary.
007	TF claim is paid during transition period due to any other circumstance.
009	TF claim is paid via an emergency fill scenario but required a prior authorization.
010	TF claim is paid via an emergency fill scenario and was considered non-formulary.
011	TF claim is paid via an emergency fill scenario due to any other circumstance.
013	TF claim is paid via a level of care change scenario but required a prior authorization.
014	TF claim is paid via a level of care change scenario and was considered non-formulary.
015	TF claim is paid via a level of care change scenario due to any other circumstance.

TF Window and Supply Limitsmixed

TF Window	First 90 days of enrollment; transition fills available at POS within this period.
Non-LTC supply	Up to cumulative 30-day supply within first 90 days; multiple fills allowed to reach applicable month's supply (30-day month).
LTC cumulative supply	Up to cumulative 31-day supply; oral brand solids limited to 14 days unless SCC 21-36 or CMS exception applied.
LTC lookback	120-day lookback on GPI-14 and Patient Location Code to detect prior LTC claims for Level of Care changes.

LTC SCC Codes and Examplesmixed

SCC (Submission Clarification Code)	Used on POS claims for LTC Emergency Supply and Level of Care change scenarios; example SCC 420-DK value '18' for LTC LOC indication.
SCC 21-36	Indicates LTC dispensing of varying days' supply and allows exception to 14-day limit for oral brand solids when used.

Reject and Status Codesmixed

79	Refill Too Soon (RTS) reject returned when claims hit RTS edit; automated TF does not override RTS except for LTC Level of Care Change.
88	DUR safety edit reject returned when claims hit DUR edits set to reject; automated TF does not override DUR rejects.
AG	Days supply limitation reject; message 'Resubmit for Remaining Day Supply of XX' returned when submitted days exceed remaining TF allowed supply.
R79	Alternate notation for Refill Too Soon (RTS) reject used in adjudication rules.
R88	Alternate notation for DUR reject used in adjudication rules.

Submission Clarification Codes (examples)mixed

420-DK Value '18'	Used to indicate LTC Level of Care change at POS when combined with Patient Location Code = LTC.
SCC 21-36	Indicates LTC dispensing increments/days; permits exceptions to the 14-day oral brand solids limit per CMS guidance.

Provider Actions, Overrides, and Operational Notes

Prior Authorization

Transition Fill overrides for PA, NF, and Step Therapy

Transition Fill overrides for Prior Authorization (PA), Non-Formulary (NF), and Step Therapy — Delegated PBM transition processing will override PA, NF, and eligible Step Therapy rejects at point-of-sale so that a temporary transition supply can be dispensed when the claim meets TF eligibility criteria. These overrides allow the pharmacy to receive a paid TF adjudication and return TF-specific messaging to the pharmacy.

Non-formulary (NF) TF overrides NDC Not Covered (Plan reject 70).
PA TF overrides Prior Authorization reject 75.
Step Therapy TF overrides applicable step rejects (e.g., 76/75/608 depending on plan setup) and may mark the step as satisfied for future fills in some cases.

Prior Authorization

PA overrides TF processing

Beneficiary-level clinical Prior Authorizations (PAs) that are entered to override all utilization management edits will prevent TF processing. If a clinical/beneficiary-level PA exists on the member record that overrides TF-eligible edits, the claim will not process as a TF and TF letters/notices will not be generated.

Key Definitions

Transition Fill - Medicare (TF) definition

DefinitionTransition Fill - Medicare (TF): A temporary supply of a Part D covered drug per CMS Part D requirements

PurposeProvides temporary access to Part D drugs to avoid therapy interruption while exceptions, prior authorizations, or switches to formulary alternatives are arranged

AdjudicationTF-eligible claims are auto-processed and paid at POS by the Delegated PBM adjudication system and return TF-specific POS messaging

Non-formulary Drugs definition

DefinitionNon-formulary Drugs: Part D drugs not on the Sponsor's formulary, drugs with expired exceptions, or drugs requiring PA/step therapy/quantity limits lower than the beneficiary's current dose

TF relevance

Initial / New Beneficiary Transition Fill Criteria

New Beneficiaries

Initial/new-to-plan beneficiary TF

New beneficiary TF: New beneficiaries in first 90 days of enrollment may receive TF at POS for up to a cumulative 30-day supply for non-LTC and 31-day for LTC (subject to limits), without pharmacy needing to submit PAMC or TF-specific codes.90-day window / cumulative days supply

Delegated PBM adjudication auto-processes eligible claims and sends POS messaging per NCPDP standards.

Continuation / Renewing Beneficiary Criteria

Renewing Beneficiaries

Continuation/renewing beneficiary TF during TF Window

Renewing beneficiary TF: Renewing beneficiaries during the TF Window who have history of utilization of impacted drugs are eligible for transition fills for negative formulary changes; Delegated PBM adjudication automatically processes and pays these claims up to cumulative TF days supply per plan design.TF Window / cumulative days supply

History criteria include 180-day lookback and GPI match level 10; additional supplies may be provided case-by-case via Pharmacy Help Desk.

Continuation after Step TF

When a TF satisfies a step therapy requirement:

Step TF continuation: If TF satisfies step therapy prerequisites (including grandfathering or where TF itself meets step requirements), the beneficiary may continue future fills without encountering step therapy rejects.

Step Therapy Handling During Transition

Edit	How handled during Transition Fill (POS)	Notes / Exceptions
Step therapy edits are coded to be resolved at point-of-sale (POS) during transition fill processing
POS adjudication will apply TF logic to allow claims to process and post to history appropriately; a Step Therapy transition fill notice may be generated
Safety-related DUR edits and Part A/B determinations are not TF-bypassed (see DUR exclusions)

Edit Type	TF POS behavior	Exclusions / Safety edits
TF-eligible step therapy, PA and non-safety quantity limit edits are resolved at POS and may be overridden for eligible TF claims
Delegated PBM adjudication applies TF logic at POS to allow temporary supply and posts fills to history; MIC handling may vary by benefit setup
DUR safety edits (therapeutic duplication, cumulative acetaminophen, MME, drug interaction, age alerts) are set to reject and are excluded from TF overrides

Capability	Effect on claim	Operational result
TF can override step therapy rejects at POS allowing the claim to adjudicate and post to history
In some cases (e.g., grandfathered or Type 2 ST-PA scenarios), the TF itself satisfies step therapy prerequisites so future fills do not reject
When TF satisfies step requirements, Step TF Letters may not be sent to beneficiaries or prescribers; claim posts as meeting step criteria in history

Feature	Scope / Lookback	Impact when Sponsor selects Type 2
Type 2 ST-PA edits are configured as step edits for new starts to therapy only
Delegated PBM uses a 108-day minimum lookback period to identify new starts under Type 2 logic
If Sponsor selects Type 2 ST-PA logic, claims for applicable new starts will pay according to plan ST-PA rules (pay without TF logic)

Transition Supply and Quantity Limits

Transition supply (general)

Non-LTC cumulative limitCumulative 30-day supply for Non-LTC TF claims during the first 90 days of enrollment

LTC cumulative limitCumulative 31-day supply for LTC TF claims during the first 90 days of enrollment

LTC oral brand solidsOral brand solids limited to 14-day fills in LTC without SCC 21-36 or CMS exception

Multiple fills allowedMultiple fills permitted to reach the cumulative applicable month's supply when prescriptions are written for less than a month's supply

Transition extension supply

Transition extension supply30-day supply allowed for transition extension when exception requests or appeals remain pending (Sponsor 2026 setup)

Site of Care and POS Identification

Note

Support transition fills in non‑LTC and LTC with distinct rules

Transition fills are supported in both non‑LTC (retail, mail, home infusion) and LTC settings; POS processing uses Patient Residence and Pharmacy Service Type codes to identify LTC versus non‑LTC and apply distinct supply rules.

Non‑LTC cumulative TF = up to 30 days within TF window
LTC cumulative TF = up to 31 days (oral brand solids limited per SCC rules)

Billing Rule

Use network, Pharmacy Service Type and PLC to identify site of care

TF parameters vary by network and Patient Residence codes (retail, mail, LTC, home infusion); pharmacies must submit Pharmacy Service Type and Patient Residence/PLC values so claims are identified correctly for TF processing.

PLC 03 and SCC values are used internally to map LTC claims

Biosimilar Handling

Billing Rule

Treat biosimilars as non‑interchangeable for TF processing

Delegated PBM will handle biosimilars as non‑interchangeable brand/generic products for transition fill processing and will apply the appropriate cost share per CMS guidance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policy2026 Transition Fill Policy

Policy CodePolicy 000988

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateJun 1, 2026

Key ActionDelegated PBM will auto-pay eligible transition-fill claims at point of sale and send a transition notice to the beneficiary within 3 business days after adjudication.

SourceLink

On This Page

rolling 30-day lookback

POS submitted with appropriate SCC values and LTC PLC; allows emergency fills while exception pending.

Quantity Limits TF: TF overrides quantity vs time (QvT) or maximum daily dose (DD) rejects allowing claims to process via TF logic during transition period; QvT TF takes precedence over DD TF when both present.varies by plan setup

QL TF overrides reject code 76; system compares history vs current QL to allow override when current QL is lower than history.

Step Therapy TF: TF can override step therapy rejects and may satisfy step requirements for future fills in some cases; Step TF may generate notices, and TF may replace need for PA in certain scenarios.plan-specific

Step TF overrides reject 76/75 or 608 depending on plan setup.

This logic ensures beneficiaries receive an entire pre-packaged quantity when appropriate.

Type 2 ST-PA override: Type 2 ST-PA Drug Logic for new starts uses a 108-day lookback; if Sponsor selects this logic the claim will pay without TF logic; TF processing applies to TF-eligible edits not overridden.108 days

Delegated PBM uses 108-day minimum lookback to determine new starts for Type 2 ST-PA.

TF claims history accumulation: All history for a drug during the transition period is counted across POS, manual, paper, retail, mail, LTC and home infusion to determine cumulative days supply for TF eligibility.

History accumulation is at GPI 14 and unique edit type by Beneficiary across networks.

New beneficiary transition handling: If POS cannot distinguish a brand-new versus ongoing prescription for a non-formulary drug, the transition process is applied as a brand-new prescription; transition fills available at POS during TF Window; additional supplies available case-by-case via Pharmacy Help Desk.

New beneficiaries include those new at Contract Year start, newly eligible from other coverage, or switching plans after Contract Year start.

TF letter generation and language: Paid TF claims are extracted to a daily TF Claim File; TF Claim Tags and TF Letter Tags determine letter content; daily files drive beneficiary and prescriber letters and support multilingual communications when indicated; letters are sent within 3 business days after adjudicated TF claim.3 business days

TF Combo Tag used when multiple edits overridden to include paragraphs for each edit.

Renewing beneficiary transition criteria: Renewing beneficiaries require history utilization demonstrated by a 180-day lookback, GPI match level 10, and prior history claim(s) for same drug; negative formulary changes are evaluated at POS and renewing beneficiaries may receive transition fills during the first 90 days of the Contract Year per described conditions.180 days; 90 days

Sponsor may implement additional outreach (ANOC) or prospective transition activities.

TF extensions and sponsor help desk: TF Extensions are available through Pharmacy Help Desk or Customer Care for outside-standard TF days supply or pending PA/exception decisions; requests are reviewed and processed per Sponsor instructions.

Extensions apply to new or existing beneficiaries, LTC or non-LTC.

Monitoring and reporting: TF program performance monitoring includes TF Claim Extract Control, TF Letter Print QC, TF Response File, TF Letter TAT reports, Paid TF Claim File, Rejected Claim File, and ability to process paid mock TF claims for testing.

Reporting supports internal and Sponsor monitoring of TF operations.

Denial Risk

Claims not eligible for transition fills

Claims not eligible for transition fills may be rejected or returned to the pharmacy. Common non-TF triggers include drugs excluded from Part D, Part A/B vs Part D determination edits, certain DUR safety edits, Refill Too Soon (reject 79), and days-supply (AG) limits when remaining TF days are exhausted. Pharmacies should review returned reject codes and resubmit with corrected days supply or seek a manual override when appropriate.

Non-Part D or excluded drugs will be rejected and not paid under TF rules.
DUR safety edits (therapeutic duplication, cumulative acetaminophen, MME, interactions, age alerts) are set to reject and are not TF-overridden.
Refill Too Soon (reject 79) is not overridden by automated TF logic except for specified Level of Care changes.
AG reject: when requested days exceed remaining TF cumulative days, message 'Resubmit for Remaining Day Supply of XX' is returned.

Billing Rule

Level of Care identification and POS submission

Level of Care (LOC) changes are identified in adjudication by matching the submitted drug to prior claims within the most recent 120 days at the GPI 14 level with a Patient Location Code indicating LTC. For non-LTC residents whose claim indicates an LOC change and who hit Refill Too Soon or DUR rejects, the system may automatically provide a LOC transition fill; otherwise pharmacies may obtain a manual override via the Pharmacy Help Desk.

LOC detection uses GPI 14 lookback of 120 days and Patient Location Code indicators.
Non-LTC residents allowed up to cumulative 30-day supply (or greater per benefit design); LTC LOC rules provide cumulative 31-day supply (oral brand solids limited to 14 days unless SCC 21-36).
POS submission for LTC LOC should include Submission Clarification Code 420-DK value '18' and Patient Location Code identified as LTC when applicable.

Step Therapy

Step therapy and DUR handling

Step therapy and certain DUR handling during transition — Delegated PBM will resolve TF-eligible Step Therapy and non-safety quantity limit edits at POS so the claim can be paid under TF rules. However, DUR safety edits and some safety-related quantity limits remain non-TF and will reject at POS. When step TF is applied for specific Type 2 (new-start) scenarios, the TF itself may satisfy the step requirement so future fills will not re-trigger the step edit.

TF bypasses non-safety step therapy and non-safety quantity limit edits at POS so temporary supply can be dispensed.
DUR safety edits (therapeutic duplication, cumulative acetaminophen, MME, interactions, age alerts) are excluded from TF overrides and will return reject 88.
Refills dispensed for less than the written amount due to safety/quantity edits are allowed multiple fills up to at least a 30-day cumulative TF supply.
When TF satisfies a Step Therapy requirement (in some Type 2 cases), future fills may process without re-triggering step rejects and no Step TF letters are produced.

Step Therapy

Type 2 Step Therapy (ST-PA) handling

Type 2 Step Therapy (ST-PA) handling — Type 2 ST-PA edits (step for new starts only) are adjudicated using a 108-day lookback to determine new starts. If the Sponsor elects Type 2 logic, claims meeting the Type 2 criteria may be paid according to plan criteria without applying TF logic. TF will apply to any TF-eligible edit not overridden by the Type 2 ST-PA logic.

Delegated PBM uses a 108-day minimum lookback for new-start determination on Type 2 ST-PA drugs.
If Type 2 ST-PA logic deems the claim payable under plan criteria, the claim pays without TF processing; otherwise TF processing may be applied to other eligible edits.

Non-formulary Part D drugs may be eligible for TF overrides to allow temporary supply while exception requests are pending

Cost sharingNon-formulary transition supply receives the same cost sharing that would apply if a non-formulary exception were approved

Biosimilars definition

DefinitionBiosimilars: Biological products approved via the FDA's biosimilar pathway; for TF, Delegated PBM treats biosimilars as non-interchangeable brand/generic products

TF handlingBiosimilars are handled as non-interchangeable in transition fill processing and appropriate cost share is applied per CMS guidance

Regulatory noteBiosimilar designation is determined by FDA approval pathway and interchangeability standards

LTC Emergency Supply (ES) definition

DefinitionLTC Emergency Supply (ES): A TF condition allowing a cumulative 31-day supply after TF parameters are exhausted while a coverage determination or exception is pending

Oral brand solids limitOral brand solids are limited to 14 days for ES unless SCC 21-36 or CMS exception applies

Frequency limitsES is limited to one ES every rolling 30 days and one ES per LTC stay (per policy setup)

LTC Level of Care Change (LOC) definition

DefinitionLTC Level of Care Change (LOC): A TF condition triggered when a beneficiary is admitted to or discharged from an LTC facility, identified via PLC/Patient Residence codes and matching prior claim history

POS identificationIdentified by matching submitted drug to a claim within prior 120 days on GPI 14 with a Patient Location Code indicating LTC; POS submission should include appropriate SCC/PLC when applicable

Supply allowanceAllows cumulative TF days supply per LTC LOC benefit (generally up to 31 days for LTC) and can override certain RTS/DUR rejects at POS when correctly submitted

NDC definition

DefinitionNDC: National Drug Code — a unique, three-segment numeric identifier assigned to each medication listed under Section 510 of the Federal Food, Drug, and Cosmetic Act (missing definition added in this version)

Document changeVersion notes removed duplicate NCPDP entry and added the missing NDC definition in this revision

In these cases, Step TF Letters may not be sent to beneficiaries or prescribers and TF will post to history so future fills do not reject.

ProcessExtensions provided case-by-case via Pharmacy Help Desk or Customer Care while exception/PA decisions are pending

Cross-year ruleTransition policy extends across Contract Years for beneficiaries enrolling effective Nov 1 or Dec 1 to provide needed transition supply

All TF-eligible drugs

Non-LTC ruleNon-LTC TF-eligible drugs: cumulative 30-day supply within first 90 days of enrollment

LTC ruleLTC TF-eligible drugs: cumulative 31-day supply within first 90 days of enrollment; oral brand solids limited to 14 days unless SCC 21-36 or CMS exception applies

Multiple fillsMultiple fills allowed across settings (retail, mail, LTC, home infusion) to accumulate the cumulative TF days supply

generic/applicable drugs

Generic/applicable drugs allowanceCumulative TF days supply as allowed by plan (e.g., 31 days for LTC ES); oral brand solids limited to 14 days in LTC unless SCC 21-36 applies

AG reject handlingClaims exceeding remaining allowed TF cumulative days supply return an 'AG' reject; reduce days supply and resubmit for remaining days to process under TF rules

Unbreakable packagingIf manufactured packaging cannot be split, a single package may be dispensed even if it results in days supply exceeding typical limits, per policy logic

Different TF days supply accommodated by network/list mappings

Billing Rule

Submit PLC/Pharmacy Service Type to identify LTC vs non‑LTC

Pharmacy Service Type and Patient Residence/PLC values on submitted claims identify LTC versus non‑LTC so TF parameters and reimbursement apply correctly per benefit design.