Currentsanford health planPolicy N/A
Transition Policy 2025 Medicare
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Defines Sanford Health Plan's process for providing temporary access to Part D drugs when enrollees present prescriptions that are non‑formulary or subject to utilization management, and describes who and what situations are covered by the transition process.
Policy Summary
Payersanford health plan
PolicyTransition Policy 2025 Medicare
Policy CodePolicy N/A
Change TypeAnnual review
Effective DateN/A
Last ReviewMay 17, 2024
Next Review DateMay 18, 2025
Key ActionPrescribers or members may initiate prior authorization or exception requests when a transition claim pays; medical necessity review is required for non‑formulary or UM-controlled drug requests.
SourceLink
POLICY UPDATE CHANGES
Version 11 includes an annual review/approval entry dated 5/17/2024.
Past versions document updates such as changing the transition window to 108 days and removing a one-time override for temporary month's supply.
108standard transition period (days)
1 monthretail transition fill
31LTC emergency minimum (days)
case-by-caseextensions
quarterlyreporting cadence
Transition Coverage Criteria and Procedures
Transition coverage criteria and procedures
The Company will provide temporary transition supplies and evaluate non-formulary and UM-controlled drug requests according to medical necessity and CMS requirements.
Provide temporary transition supplies for Part D drugs that are non-formulary or that are on the formulary but require prior authorization, step therapy, or have a quantity limit lower than the beneficiary's current dose (UM-controlled).
ALL of the following
- Other formulary or covered drugs would not be as effective or would have adverse effects
- No formulary or covered drug would be as effective or would have adverse effects
- Formulary alternative has caused or is likely to cause an adverse reaction or other harm based on sound clinical evidence
ALL of the following
- Provide a transition letter to member and prescriber describing the temporary nature of the fill and how to request an exception or prior authorization
- Allow prescriber to suggest and prescribe therapeutically appropriate formulary alternatives
- Prescriber or member may initiate a prior authorization or exception request if no appropriate formulary alternative exists
- Notify members of appeal (redetermination) rights if a medical necessity coverage determination is denied; appeals may be initiated and processed expeditiously upon request
Transition coverage criteria
Coverage stance for temporary transition supplies and handling of UM/formulary edits during transition periods.
Retail temporary supply: provide at least a one-time temporary month's supply in the retail setting during the first 108 days of enrollment (beginning on the enrollee's effective date); if prescription written for less than a month, allow multiple fills to total a month's supply; allow fills for unbreakable packages
Cost sharing: charge cost-sharing on transition fills consistent with client cost-sharing tiers; for LIS enrollees cost-sharing will not exceed statutory caps; insulin and ACIP‑recommended Part D vaccines capped per statutory maximums
LTC supply: provide a month's supply consistent with dispensing increments during first 108 days; after transition period expires provide a 31‑day emergency supply while an exception or prior authorization is requested; do not enforce early-refill edits to limit access on admission/discharge
Override UM edits at point-of-sale during transition: non-formulary, prior authorization, step therapy, and quantity limit edits (except Part A/B vs Part D determinations, rejects for non-Part D drugs, labeling/safety QLs, and early-refill edits) are overridden to allow paid transition claims and multiple fills up to the transition days' supply limit; no hard edits that prevent payment during transition
Protected class drugs: enrollees who receive a transition supply of a PA or ST protected-class drug may continue that medication throughout the benefit year without being treated as new starts and are not to be sent a transition letter
Notification: mail written notice to the enrollee and prescriber within three business days of adjudication of a temporary fill using CMS‑approved template; letter explains temporary nature, instructions to work with prescriber/plan, and right/procedures to request a formulary exception
Claims messaging: the claims system auto-identifies transition-eligible products and returns appropriate NCPDP/response messaging to the pharmacy; when the transition period ends, the system will reject claims that require PA or are non-formulary until resolved
Across-contract-year (negative formulary change) options: plan sponsor may either (1) apply new-enrollee transition process at the start of the new contract year or (2) effectuate transitions prior to Jan 1 and complete exceptions/authorizations prior to Jan 1; if not transitioned, provide transition supply beginning Jan 1
Extension requests: permit case-by-case extension of transition supply while exception/appeal is pending; requests may be initiated by beneficiary, authorized representative, prescriber, or pharmacy via phone, mail, fax, email, or website
Safety and labeling edits: certain safety-based quantity limits and early-refill edits may still apply during transition to ensure safe utilization; these are handled at point-of-sale by pharmacist or Member Services
Automated identification: system uses patient residence codes and other indicators to identify level-of-care changes and permit transition overrides; if not auto-identified pharmacist may contact Pharmacy Help Desk for one-time authorization
Forms availability: prior authorization and exception request forms are made available by mail, fax, email, and on plan sponsor websites
Transition coverage criteria
Criteria and operational rules for providing transitional fills and managing exceptions across scenarios:
New-enrollee transition: provide at least a one-time temporary retail fill of up to a month's supply during the first 108 days of enrollment for non-formulary or UM-controlled drugs; allow multiple fills if prescription written for less than a month
LTC transition: in long-term care provide a one-time temporary fill of at least a month's supply (dispensed incrementally as applicable) during the first 108 days; after transition period expires provide a 31-day emergency supply while exception/PA is requested; early-refill edits are not used to limit access on admission/discharge
Cross-year transitions for current enrollees affected by negative formulary changes: either (1) provide transition at start of new contract year consistent with new-enrollee process, or (2) effectuate transitions prior to Jan 1 and complete exceptions/authorizations prior to Jan 1; if not transitioned, provide transition supply beginning Jan 1 consistent with the new-enrollee process
Extension cases: extend transition on a case-by-case basis until exception request or appeal is processed when requests are not resolved by the end of the minimum transition period; requests may be made by beneficiary, representative, prescriber, or pharmacy via written, phone, email or fax
Point-of-sale UM behavior during transition: apply only edits necessary to determine Part A/B vs Part D, prevent coverage of non-Part D drugs, and promote safe utilization; step therapy and prior authorization edits must be resolved (served via paid transition claims) and not enforced as hard rejections at POS
Cost-sharing limits and reporting: cost sharing on transition fills for LIS enrollees will not exceed statutory LIS copayment amounts; sponsors provide quarterly transition fulfillment and compliance reports to client advisors and Part D sponsor as required for monitoring
Codes, Thresholds, and Lookbacks
Transition codesmixed
| Prior Authorization, Step Therapy Transition Codes | Two-letter codes used to specify the type of transition fill. |
Transactional messaging codesmixed
| NCPDP message codes | Use of NCPDP-approved message codes in pharmacy response to indicate transition status or rejects. |
Not specified in this sectionmixed
| No codes listed |
inv-07: Quantity and lookback thresholds
Transition window (standard)108-day transition window (Company standard; CMS auditors use a 108-day lookback)
LTC emergency supply minimumAt least 31 days' supply for LTC residents (multiple fills allowed if prescription written for less than 31 days)
Retail temporary fill minimumOne-time temporary retail fill of at least a one-month supply; multiple fills allowed to equal one month if Rx written for less
inv-08: transition days' supply limit
Transition days' supply limitMultiple fills are allowed up to the maximum allowable days' supply of a transition supply as defined by the transition policy; UM edits (non-safety) are overridden to permit fills up to this limit
Refill behavior for QLs/safety editsIf dispensed for less than written amount due to safety QLs, enrollees must be allowed refills to reach the transition supply limit
No hard POS editsNo hard edits are used to manage transition supplies during the transition period so claims pay without pharmacist override
inv-09: ongoing therapy lookback
Ongoing therapy lookbackApplied for current enrollees affected by negative formulary changes: beneficiaries who utilized the drug during the past at least 120 days are eligible for transition supply beginning Jan 1
Cross-year applicationPolicy extends across contract years (e.g., Nov/Dec effective dates) to provide transition supply if not transitioned before Jan 1
Extension while appeals pendingTransition period may be extended case-by-case until exception/appeal resolved
What Providers, Pharmacies, and Members Must Do
Prior Authorization
Initiate PA/Exception after Paid Transition Claim
If a transition claim pays for a non‑formulary or UM‑controlled drug, the prescriber or the member may initiate a prior authorization or exception (coverage determination) request; medical necessity will be determined using the prescriber's supporting statement and clinical guidelines, and members are notified of appeal rights if a request is denied.
- Prescriber or member may initiate PA/exception after a paid transition claim.
- Medical necessity determination uses prescriber supporting statement and adopted clinical guidelines.
- Members are notified of appeal/redetermination rights if denied.
Prior Authorization
One‑time Authorization via Pharmacy Help Desk for Level‑of‑Care Changes
When a level‑of‑care change is not automatically identified by residence code, the pharmacist must call the Pharmacy Help Desk to notify them so a one‑time authorization can be entered to allow the claim to pay; these authorizations are entered as one‑time and additional one‑time authorizations must be entered for subsequent level‑of‑care changes.
- Pharmacist calls Pharmacy Help Desk if system did not auto‑identify level‑of‑care change.
- Help Desk places a one‑time authorization to override rejects and permit payment.
- Enter additional one‑time authorizations for subsequent level‑of‑care changes.
Documentation Required
Prospective Exception or Temporary Supply and Availability of Forms
Plans will either offer to process a prospective exception request at the start of the plan year or provide a temporary supply with written notice instructing the enrollee to switch to a formulary alternative or request an exception; PA and exception request forms are made available via mail, fax, email, and plan websites for convenience.
- Option to process a prospective exception request at plan year start if prior exception will not be honored.
- Provide temporary supply at plan year start with notice instructing enrollee to switch or request an exception.
- PA and exception forms available by mail, fax, email, and on plan websites.
Documentation Required
Extension Requests and Access to PA/Exception Forms
Beneficiaries, authorized representatives, prescribers, or pharmacies may request extensions of the transition period if exception requests or appeals remain unresolved; prior authorization and exception forms will be made available upon request via mail, fax, email, and plan websites.
- Extension requests may be initiated by beneficiary, authorized representative, prescriber, or pharmacy.
- Requests may be submitted in writing, by phone, email, or fax.
- PA/exception forms available upon request via mail, fax, email, and plan websites.
Prior Authorization
Limited POS UM Edits; Part A/B Distinction and Non‑Part D Prevention
During the transition period only limited utilization management edits are applied at point‑of‑sale — edits to determine Part A/B vs Part D, to prevent coverage of non‑Part D drugs, and to promote drug safety — while step therapy and prior authorization edits are resolved so transition claims pay rather than being hard‑rejected.
- Apply POS edits for Part A vs B determination and to prevent non‑Part D coverage.
- Apply safety‑based QLs and early refill edits as needed for safe utilization.
- Step therapy and prior authorization edits are resolved (not enforced as hard rejects) so transition fills pay.
Note
Attachments
Attachments: N/A.
Note
Authority / Citations
Authority/Citations: N/A.
Key Definitions and Terms
inv-17: Transition — definition entry
DefinitionTransition: the process to provide temporary access to Part D drugs when an individual first presents at a participating pharmacy or when moving between coverage/settings, including new enrollees, newly eligible beneficiaries, plan switchers, current enrollees with negative formulary changes, and LTC residents
PurposeAllows time for therapeutic switch or exception/prior authorization processing to avoid interruptions in therapy
Regulatory basisConsistent with 42 CFR §423.120(b)(3) and CMS guidance
inv-18: Emergency Fill
Requirement for LTC residentsLTC facility residents ordered non-formulary or UM-controlled Part D drugs must receive emergency supplies without delay
Minimum emergency quantityEmergency supplies must be for at least 31 days; if prescription written for less, multiple fills must be allowed to reach 31 days' supply
Post-transition allowanceAfter the initial transition period expires, LTC residents may still receive a 31-day emergency supply while exception/PA is requested
inv-19: Transition Period
Definition (period)Transition Period: the first 108 days of coverage under a Medicare Part D plan during which temporary fills for non-formulary or UM-controlled drugs are provided
Purpose during periodAllows paid transition claims and overrides many UM edits so enrollees receive temporary supply while alternatives or exceptions are pursued
Lookback useCMS auditors use a 108-day lookback to establish ongoing therapy; Company uses 108 days standard (not 90)
inv-20: Non-Formulary Drug
DefinitionNon-Formulary Drug: a Part D drug not on the plan's formulary, or a formulary drug that requires PA, ST, or a QL lower than the beneficiary's dose and thus effectively functions as non-formulary when UM requirements are not met (excludes safety QLs and UM to validate Part D eligibility)
ScopeApplies to brand-new prescriptions for a non-formulary drug if system cannot distinguish new vs ongoing at POS
ImplicationSuch drugs are eligible for transition processes when presented during the transition period
inv-21: Level-of-care change
DefinitionLevel-of-care change: an unplanned transition between treatment settings (e.g., discharge from hospital to home, end of SNF Medicare Part A stay, discharge from psychiatric hospital, end of LTC stay) that may require transition fills because discharge medications may not reflect the patient's plan formulary
ExamplesHospital to home, end of SNF stay, discharge from psychiatric hospital, end of LTC stay
Policy actionTransition fill process is applied for these unplanned transitions
inv-22: Formulary Change across Contract Year
DefinitionFormulary Change across Contract Year: transition type where current enrollees are affected by negative formulary changes for the upcoming year and require a meaningful transition process either at or prior to the start of the new contract year
Sponsor optionsOption 1: provide transition at start of new contract year consistent with new enrollee process; Option 2: effectuate transition prior to Jan 1 and authorize payment if exception granted before Jan 1
Combination approachSponsors may combine options and encourage proactive exception requests prior to Jan 1
inv-23: Transition supply
DefinitionTransition supply: a temporary one-time fill (retail or LTC) of at least a month's supply to allow continued access while exceptions or switches are pursued
Retail and LTC parityCompany provides a one-time temporary fill of at least a month's supply in LTC and retail settings (dispensed incrementally in LTC as applicable)
Multiple fills to meet minimumIf prescription is written for less than one month (retail) or less than 31 days (LTC emergency), multiple fills are allowed to reach the minimum transitional quantity
inv-24: Cross-year transition
DefinitionCross-year transition: processes applied to current enrollees affected by negative formulary changes when enrollment effective dates occur in November or December or when changes take effect January 1
TimingCompany extends transition process across contract years for Nov/Dec effective enrollment dates; provides transition supply beginning Jan 1 if not transitioned earlier
Encouragement to providers/enrolleesEnrollees and providers are encouraged to request exceptions prior to Jan 1 to reduce January volumes
inv-25: Change Log
DefinitionChange Log: chronological record of document versions with date, summary of change, and contributor
ContentIncludes entries for past versions with dates, descriptions, and contributors (entries from 2018 onward recorded)
MaintenanceSection to be completed/filled out by Submitter and Document Control
inv-26: Version
Version identifierVersion: 11
Most recent change summary5/17/2024 — Annual Review/Approval Dates recorded
Historic notesPreviously updated transition window to 108 days (05/19/2021) and removed one-time override for temporary month's supply (10/27/2020)
Policy Summary
Payersanford health plan
PolicyTransition Policy 2025 Medicare
Policy CodePolicy N/A
Change TypeAnnual review
Effective DateN/A
Last ReviewMay 17, 2024
Next Review DateMay 18, 2025
Key ActionPrescribers or members may initiate prior authorization or exception requests when a transition claim pays; medical necessity review is required for non‑formulary or UM-controlled drug requests.
SourceLink
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