CurrentNeighborhood Health Plan of Rhode IslandPolicy 000965

2025 Transition Policy

Governs the Delegated PBM (CVS Caremark) process to implement Neighborhood Health Plan of Rhode Island's formulary transition plan for Medicare-Medicaid Plan (MMP) members to ensure continuity of drug therapy during plan transitions and formulary changes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policy2025 Transition Policy

Policy CodePolicy 000965

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionDelegated PBM will adjudicate and pay transition-eligible claims at point of sale and provide PA/exception request forms upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90TF window (minimum)

30-dayNon-LTC supply (cumulative)

31-dayLTC supply (cumulative)

3dBeneficiary notice deadline

79,88,70,75,76,608Key reject codes

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MMP transition coverage criteria

Transition coverage provisions and operational rules applied by the Delegated PBM under the Sponsor's MMP contract.

Delegated PBM implements and maintains a transition process consistent with CMS and state MMP guidance to provide temporary drug supplies to eligible beneficiaries as defined by the Sponsor's MMP contract.

Transition applies to Non-formulary MMP Drugs (including Non-formulary Part D drugs) and to formulary drugs subject to utilization management edits when configured by the Sponsor.

Temporary supply is provided at point-of-sale (POS) and adjudicated by the Delegated PBM adjudication system to pay transition-eligible claims per plan design and coding.

Cost-sharing for transition supplies follows the Sponsor's cost-sharing tiers and federal LIS statutory limits for LIS-eligible beneficiaries; non-LIS cost share for non-formulary supplies follows formulary exception cost-share rules.

Delegated PBM will send Beneficiary transition notices within three (3) business days after adjudication of a temporary fill and will use Sponsor-provided transition notice templates; prescriber notices will be sent using reasonable efforts.

Delegated PBM will support prior authorization and exception request processing and make PA/exception forms available to beneficiaries and prescribers upon request when Delegated PBM performs coverage determination functions.

Delegated PBM will maintain reporting and audit support for paid and denied transition claims and will review and update transition policy and procedures at least annually or as needed.

For 2025 the Sponsor configured plan-level transition parameters (e.g., month supply definitions and use of Delegated PBM for notices and coverage determinations) which Delegated PBM will follow when adjudicating transition claims.

Who is eligible for Transition Fills

Transition eligibility applies at POS and via manual override for the following beneficiary scenarios:

New Beneficiaries in the MMP following the annual coordinated election period.

Newly eligible MMP Beneficiaries transitioning from other coverage.

Beneficiaries who switch from another MMP plan after the start of a Contract Year.

Current Beneficiaries affected by negative formulary changes across Contract Years.

Beneficiaries residing in long-term care (LTC) facilities, including admissions and discharges.

Coverage criteria and operational rules for Transition Fills/TOC

Quantity and time limits for transition supplies:

Non-LTC: cumulative 30-day supply during the TF Window (per Sponsor plan design); multiple fills are allowed during the TF Window to reach the cumulative 30-day amount when prescriptions are written for less than a month's supply.

LTC: cumulative 31-day supply during the TF Window; brand oral solids limited to 14-day fills unless exceptions apply or an SCC 21-36 is submitted to indicate LTC dispensing increments; multiple fills consistent with LTC dispensing increments are allowed to reach the cumulative 31 days.

LTC Emergency Supply (ES): permitted to provide up to a cumulative 31 days supply (brand oral solids limited to 14 days unless SCC 21-36 submitted); ES is allowed per calendar day per beneficiary per drug per pharmacy per plan for the rolling month and limited to one ES per LTC stay unless plan design specifies otherwise.

Non-Part D drugs are excluded from Part D TF processing and are identified via the Med D field (e.g., 'N'); Medicaid TOC eligibility and cumulative days for Non-Part D drugs follow state/MMP contract and plan design.

Transition Fill coverage criteria and operational rules

Transition eligibility and overrides apply to specific edit categories and are subject to plan design, CMS guidance, and MMP contract definitions.

Eligible edit categories (may be overridden during transition)

Non-formulary Part D drugs (overrides reject code 70).
Formulary drugs subject to Prior Authorization (PA) (overrides reject code 75).
Step therapy edits (step TF may override step rejects and in some cases the TF satisfies step requirements; uses reject override code 608).

Quantity limits (QvT) and Maximum Daily Dose (DD) edits are eligible for transition overrides; transition overrides reject code 76. When both DD and QvT exist, QvT transition takes precedence.

Age edits configured for safety are eligible for transition overrides (override reject 76).

Transition fill eligibility and overrides

Eligibility for transition fills and renewing beneficiary handling

New beneficiary TF eligibility: applies from the beneficiary's enrollment effective date through the TF Window (minimum 90 days as configured by plan/MMP contract) and is available at POS for new plan entrants and other specified new-entrant scenarios.

Renewing beneficiaries impacted by negative formulary changes may receive transition fills during the TF Window provided they have qualifying utilization history (plan setup example: GPI match level 10 with a 180-day look-back) and no beneficiary-level clinical PA already in effect.

Beneficiary-level clinical Prior Authorizations, when present and effectuated, override transition-eligible edits and will prevent TF processing and generation of TF notices for that drug/beneficiary.

Transition overrides quantity limits (QL/QvT) and AG rejects for days-supply limitations are returned when submitted days exceed remaining transition days supply; cumulative transition days supply is tracked and may limit further transition fills when exhausted.

Coding, Limits, and Supply Rules

Transition codingmixed

TF	Transition Fill processing and coding applies point-of-sale messaging for temporary supply adjudication
TOC	Transition of Care coding for Medicaid temporary supply

LTC SCC usagemixed

SCC 21-36

Submission Clarification Codes indicating LTC dispensing days supply to allow exceptions to brand oral solids 14-day limit and to indicate LTC dispensing increments

Drug benefit identificationmixed

Med D field = 'Y'/'N'

Drug database flag indicating Part D eligibility ('Y') or non-Part D ('N') to include/exclude drugs from Part D TF processing

Key adjudication reject/override codesmixed

79	Refill Too Soon (RTS) reject
88	Drug Utilization Review (DUR) reject
70	NDC Not Covered / Non-formulary
75	Prior Authorization required
76	Quantity limit reject
608	Step therapy reject override code

TF Window minimum

TF Window minimum90 days (minimum) beginning on Beneficiary effective date; Sponsor set to 90 days in 2025

Sponsor 2025 setupSponsor plan configured to provide TF Window minimum of 90 days and a 30-day non-LTC month's supply for 2025

Application periodOne-time temporary fill available anytime during the first 90 days of enrollment (beginning on Beneficiary effective date)

Non-LTC cumulative days supply

Non-LTC cumulative days supply30 days cumulative during the TF Window; multiple fills allowed to reach cumulative supply

Fill limitationsLimited by amount prescribed; multiple fills permitted if prescription written for less than a month's supply

Counting methodCumulative days supply calculated on GPI-14 and not based on number of fills

LTC cumulative days supply

LTC cumulative days supply31 days cumulative during the TF Window for LTC transition fills

Brand oral solids exceptionBrand oral solids limited to 14 days unless submitted with SCC 21-36 to allow exceptions per CMS guidance

Multiple fillsMultiple fills allowed consistent with LTC dispensing increments to reach cumulative 31-day supply

LTC brand oral solids limit

LTC brand oral solids limit14 days for brand oral solids during LTC transition or emergency supply unless CMS exception applied

Exception mechanismExceptions allowed when SCC 21-36 submitted or as required by CMS guidance

ScopeApplies to Part D LTC TF and LTC Emergency Supply processing

Cumulative transition supply

Cumulative transition supply (general)Generally 30–31 days cumulative depending on Part D (non-LTC 30 days / LTC 31 days) and plan design

Variation by programMedicaid TOC cumulative days supply follows the MMP contract and state plan design and may differ from Part D limits

LTC Emergency Supply behaviorLTC ES provides at least cumulative 31 days while PA/exception pending, subject to plan design and SCC submission

Quantity limit and days-supply transition behavior

Transition vs Quantity LimitsTransition processing overrides quantity limit / quantity-over-time (QvT) rejects including Reject 76

AG reject behaviorClaims submitted for more than remaining allowed transition days return an 'AG' reject with message to resubmit for remaining transition days supply

When overrides not allowedIf transition time or days supply exhausted, quantity limit rejects (Reject 76) will continue to apply and claims will reject

Pharmacy and Provider Operational Steps

Prior Authorization

PA/Step Therapy handling and forms availability

Prior Authorization (PA) and step-therapy (ST) edits for transition-eligible claims are coded to be resolved at point-of-sale (POS). Delegated PBM provides PA/exception forms and instructions via the Pharmacy Help Desk and network communications. Pharmacies are not required to submit a PAMC or other transition-specific code for automatic POS adjudication of transition-eligible claims, but may use PAMC when submitting manual overrides via the Pharmacy Help Desk.

PA and Step Therapy edits are coded to attempt resolution at POS.
PA/exception forms and submission instructions are available from the Pharmacy Help Desk and routine pharmacy communications.
Pharmacies are not required to submit PAMC or transition-specific codes for POS automated transition adjudication; PAMC may be used for manual overrides.

Note

POS adjudication and manual override process

When a claim is transition-eligible the adjudication system will automatically process and pay the claim and return POS messaging that the claim was paid under transition rules. Pharmacies are not required to submit or resubmit a PAMC or other transition-specific code for an eligible claim to adjudicate and pay. When automated adjudication does not identify a required override (for example certain Level of Care changes), the Pharmacy Help Desk or Customer Care can manually enter a transition override which is adjudicated and tagged the same as automated POS transitions and returns the same messaging to the pharmacy.

Automated POS adjudication applies the TF PAMC and tags paid TF claims; messaging is returned to the pharmacy.
Pharmacies are not required to submit PAMC for automated POS transition claims.
Manual overrides can be entered by Pharmacy Help Desk/Customer Care when adjudication does not identify conditions (e.g., setting changes, pending exception, dosage increases). Manual overrides use the same PAMC and produce the same paid TF messaging and beneficiary letters.

Denial Risk

UM edits not transition-eligible

Certain utilization management (UM) safety edits are not transition-eligible and will reject at POS. These include Part A/B vs Part D determination edits, drugs excluded from the MMP benefit, edits supporting Part D drug status determination, and DUR safety edits (therapeutic duplication, cumulative acetaminophen, morphine milligram equivalent (MME), drug interaction, age alerts). Step therapy, prior authorization, and non-safety quantity limit edits are set to be resolved at POS.

Edits that will reject during transition: Part A/B vs Part D coverage determinations; drugs excluded from MMP benefit; Part D status determination edits; DUR safety edits (therapeutic duplication, cumulative acetaminophen, MME, drug interaction, age alerts).
Step therapy, Prior Authorization and non-safety quantity limit edits are configured to be resolved at POS where possible.

Note

Transition extension process

If a transition-related PA/exception decision is pending when the TF window expires or the transition cumulative days supply is exhausted, pharmacies or prescribers may request extensions. The Pharmacy Help Desk or Customer Care can enter manual transition overrides on a case-by-case basis (for example when a Beneficiary requests an exception and decision is pending, or when a dosage increase is needed). Manual overrides are adjudicated and tagged the same as automated POS transitions; beneficiary transition letters are produced for manual overrides as for POS overrides.

Extension/override situations include: Beneficiary requested exception pending when TF expires; dosage increases; setting changes not auto-identified by adjudication.
Pharmacy Help Desk/Customer Care can enter manual overrides; these are processed like automated transitions and generate the same beneficiary communications.

Billing Rule

Non-LTC LOC automatic POS TF or manual override

For non-LTC residents who are undergoing a Level of Care (LOC) change from LTC to non-LTC, the adjudication system can automatically provide a transition fill at POS if the claim would otherwise reject for Refill Too Soon (R79) or DUR (R88) and the system identifies the LOC change in the recent claim history. If the adjudication does not automatically identify the LOC change, the pharmacy should contact the Pharmacy Help Desk to obtain a manual override.

Automatic POS LOC transition-eligible fills apply when adjudication detects a recent LTC claim history (lookback rules) and claim would reject for RTS (R79) or DUR (R88).
If not auto-identified, pharmacy must call Pharmacy Help Desk to request a manual LOC transition override.
Non-LTC LOC transitions allow up to the plan's cumulative non-LTC transition days supply (e.g., cumulative 30-day supply for 2025 plan setup) with multiple fills allowed to reach the applicable month's supply.

Billing Rule

LTC LOC and LTC ES submission and override

LTC Level of Care (LOC) transitions and LTC Emergency Supply (ES) require specific Submission Clarification Codes (SCC) and Patient Location coding at POS to trigger automated LTC processing. Examples: SCC 420-DK value '18' is used for LTC LOC and SCC 420-DK value '7' for LTC ES; the Patient Location Code must indicate LTC. When submitted correctly, SCC-driven LTC LOC and ES overrides will adjudicate at POS to allow the LTC LOC/ES transition fills (e.g., cumulative 31-day supply, brand oral solids limited to 14 days without SCC 21-36 exceptions). If the pharmacy cannot submit the correct SCC or needs a different quantity, the Pharmacy Help Desk can process manual overrides.

SCC 420-DK Value '18' = LTC Level of Care Change submission; SCC 420-DK Value '7' = LTC Emergency Supply submission.
Patient Location Code must identify the beneficiary as LTC to trigger LTC POS logic.
LTC LOC: cumulative 31-day supply (brand oral solids limited to 14 days unless SCC 21-36 used as allowed by CMS), one LOC transition per calendar day per beneficiary per drug per pharmacy per plan.
LTC ES: allowed per rolling 30 days (one ES per LTC stay), cumulative 31-day supply (brand oral solids limited to 14 days unless SCC 21-36).
If incoming LTC LOC/ES exceed maximum benefit, pharmacy is messaged with remaining TF benefit available through TF Window.

Step Therapy

Prior Authorization and Step-Therapy behavior

Beneficiary-level clinical Prior Authorizations override all transition-eligible edits. When a beneficiary-level PA is present on the beneficiary record, claims will not process as transitions (transition processing is not applied and transition letters are not sent). Type 2 ST-PA Drug Logic (step edits for new starts) uses a minimum lookback (108 days) to determine new starts; when this logic or a beneficiary-level PA applies, TF processing will not apply to edits the PA/Type 2 logic overrides.

Beneficiary-level clinical PAs override transition edits; claims with an applicable beneficiary-level PA will not be processed as transitions and will not trigger transition letters.
Type 2 ST-PA Drug Logic applies to new starts (108-day lookback); if it pays per plan criteria, TF logic will not apply to that edit.
TF processing applies only to TF-eligible edits that have not been overridden by beneficiary-level PA or applicable Type 2 ST-PA logic.

Key Definitions

Transition Fill (TF)

DefinitionTransition Fill (TF): A temporary supply of a Part D covered drug per CMS Part D requirements paid under the MMP benefit.

PurposeProvides temporary supply to ensure continuity of therapy during plan transitions and while exceptions/PAs are pending

POS processingTF processing uses point-of-sale logic to adjudicate and pay eligible claims under the MMP benefit

Transition of Care (TOC)

DefinitionTransition of Care (TOC): A Medicaid plan process to provide a temporary supply of a drug paid under the Medicaid benefit of an MMP product.

Plan-specificMedicaid TOC eligibility, cumulative days supply and procedures are defined by the MMP contract and state-specific plan design

IdentificationNon-Part D and TOC-eligible Medicaid drugs are identified in the drug database (Med D field) and coded at GPI level for processing

Non-formulary MMP Drugs

DefinitionNon-formulary MMP Drugs: includes Non-formulary Part D drugs and Non-formulary Medicaid benefit drugs as defined by formulary placement and utilization management edits.

ScopeIncludes Part D drugs not on Sponsor's formulary and Medicaid drugs not on the Sponsor's ADD file or requiring UM edits

Medical reviewMedical review available for Non-formulary MMP drug requests; process to identify formulary alternatives when medical necessity not met

Biosimilars handling

Handling approachBiosimilars will be treated as non-interchangeable brand/generic products for transition fills and appropriate cost share applied per CMS guidance

Cost-shareDelegated PBM will apply the appropriate cost share for biosimilars consistent with CMS guidance and program rules

Operational impactBiosimilars are included in transition logic and processed per the same TF/TOC rules as other drugs

Transition-eligible beneficiary

Transition-eligible beneficiary groupsNew or renewing MMP beneficiaries, beneficiaries switching plans, newly eligible beneficiaries, current beneficiaries affected by negative formulary changes, and beneficiaries residing in LTC facilities

POS eligibilityEligibility is applied at POS by adjudication system for the listed beneficiary scenarios

Manual overrideManual overrides via Pharmacy Help Desk or Customer Care available when adjudication does not auto-identify eligibility

Med D field

Med D field values'Y' or 'N' indicator in the drug database used to identify Part D-eligible drugs for TF processing ('N' indicates non-Part D / Med A/B only)

UsageUsed to exclude Part A/B only drugs from Part D TF processes and to route Medicaid TOC processing

Sponsor listsSponsors provide TOC eligible drug lists that are coded at GPI level to support Med D logic

LTC Level of Care Change

LTC LOC definitionLTC Level of Care Change (LOC): transition condition for LTC admissions/discharges allowing LTC LOC TF processing and overrides

SCC usageRequires Submission Clarification Code (e.g., SCC 420-DK value '18') and Patient Location Code indicating LTC to trigger LTC LOC behavior

LimitsLTC LOC allowed per calendar day, per beneficiary, per drug, per pharmacy, per plan within the defined LTC LOC benefit and counts toward cumulative LTC LOC benefit

LTC Emergency Supply

DefinitionLTC Emergency Supply (ES): An emergency transition supply provided after TF parameters exhausted/expired while exception or PA pending

Supply limitsPart D LTC ES provides at least cumulative 31 days supply (brand oral solids limited to 14 days unless SCC 21-36 submitted); allowed per rolling 30 days and limited to one ES per LTC stay

Submission codesTriggered at POS when pharmacy submits SCC 420-DK value '7' with Patient Location Code indicating LTC

Part A/B vs Part D drugs

DefinitionPart A/B vs Part D drugs: drugs requiring determination of whether covered under Medicare Part A/B or Part D and excluded from automatic Part D TF processing

Adjudication behaviorAutomated TF logic not applied; claims reject with structured NCPDP messaging instructing plan contact for coverage determination

Database flaggingTagged as 'N' in Med D field or identified with Prior Authorization table flags for special processing

QL/QvT transition

QL/QvT transitionQuantity limit and Quantity-over-Time (QvT) edits may be overridden during transition processing; transition overrides Reject 76

DD interactionDD (Maximum Daily Dose) edits are mutually exclusive with QL/QvT; if both present, QL/QvT transition takes precedence

Plan limitsTransition can override plan limitations set on certain plan options when QvT transition applies, but cumulative transition days supply still limits further transition fills

AG Reject

AG Reject meaningAG Reject: a claim reject due to days supply limitation that returns code 'AG' with message 'Resubmit for Remaining Day Supply of XX'

When returnedReturned when submitted days exceed remaining allowed transition cumulative days supply; appears on initial and subsequent submissions when applicable

Resubmission guidancePharmacy may reduce days supply and resubmit to process under transition rules; messaging retained on claim

Unbreakable pre-packaged medication

DefinitionUnbreakable pre-packaged medication: a drug whose manufactured packaging cannot be split; TF may pay for a full package to ensure beneficiary receives entire transition supply

Payment logicTF will pay when pre-packaged medication cumulative DS is less than required benefit and current fill quantity is less than or equal to single package quantity

Resubmission requirementIf current fill quantity exceeds single package quantity and exceeds benefit, pharmacy will be messaged to resubmit for a single package

OpenPayer

2025 Transition Policy

Transition Coverage Criteria

Coding, Limits, and Supply Rules

Pharmacy and Provider Operational Steps

Key Definitions