CurrentUCarePolicy N/A

Part D Prescription Drug Transition Policy

Defines UCare's temporary prescription refill (transition) policies for Part D drugs when members cannot immediately obtain their medications, covering retail and long-term care settings and who is eligible.

Policy Summary

PayerUCare

PolicyPart D Prescription Drug Transition Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionProvide a temporary supply while prior authorization, step therapy, or exception requests are processed (30 days retail; 31 days long-term care).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysminimum retail transition supply

31 daysminimum LTC transition supply

90 daystransition eligibility window

3 business daysmember notice timeline

Transition Coverage Criteria

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Retail Transition: For retail settings: member is a new enrollee within the first 90 days of eligibility OR a current member taking medications that are no longer covered or are subject to new formulary restrictions within the first 90 days of a new contract year; UCare will provide a temporary supply of non-formulary Part D drugs for at least 30 days (unless the prescription is written for less). This includes Part D drugs that are on the formulary but require prior authorization or step therapy.

Long-Term Care Transition: For members in long-term care: member is a new enrollee within the first 90 days of eligibility OR a current LTC resident taking medications that are no longer covered or are subject to new formulary restrictions within the first 90 days of a new contract year; UCare will provide a temporary supply of non-formulary Part D drugs for at least 31 days (unless the prescription is written for less) and will honor multiple fills as needed up to a 31‑day supply. This includes Part D drugs that are on the formulary but require prior authorization or step therapy.

LTC Emergency Supply: Emergency supply in long-term care: for LTC residents outside the 90-day transition period, UCare will provide an emergency supply of non-formulary Part D drugs while an exception is being processed for at least 31 days (unless the prescription is written for less). UCare will honor multiple fills as necessary up to a 31‑day supply. This includes Part D drugs that are on the formulary but require prior authorization or step therapy.

Level of Care Changes: Level-of-care changes: when a current member has a change in level of care (for example, admission to or discharge from a long-term care facility or other institution) during discharge planning, the transition process applies and UCare will waive early-refill notices to prevent delays in medication access.

Transition Extension: Transition extension: if an exception request or appeal is unresolved by the end of the minimum transition period, UCare may extend the transition on a case-by-case basis; the extension ends when the medication is changed to a formulary drug or the exception/appeal is decided.

Provider Actions and Operational Requirements

Prior Authorization

Temporary supply pending prior authorization/step therapy

Temporary supply pending prior authorization or step therapy. When a member presents a prescription for a Part D drug that is on the formulary but requires prior authorization or step therapy, UCare will provide a temporary supply while the authorization or step process is completed. The temporary supply is intended to allow continuity of therapy and is not a guarantee of ongoing coverage.

Applies to formulary drugs requiring prior authorization or step therapy.
Retail setting: at least a 30-day supply (unless prescription written for less than 30 days).
Long-term care setting: at least a 31-day supply and multiple fills may be honored as needed up to a 31-day supply while transition applies.
Temporary supply ends when the prior authorization/step therapy is approved, denied, or the transition period expires.

Step Therapy

Temporary supply for step therapy drugs

Step-therapy temporary supply rules. Specific step-therapy transition rules differ by setting; ensure the appropriate supply duration and refill rules are followed for retail vs long-term care.

Retail: Provide a temporary supply for at least 30 days for members within the 90-day transition period.
Long-term care (LTC): Provide a temporary supply for at least 31 days; multiple fills may be authorized as needed up to a 31-day supply during the transition period.
Outside the 90-day transition window for LTC residents, UCare will still provide an emergency supply while an exception or prior authorization is being processed.

Documentation Required

Member notice after transition

Member notice after transition fill. UCare will send a written notice to the member within three business days of the transition fill explaining that the supply is temporary, how to work with the prescriber to find alternatives, and how to request a formulary exception.

Notice includes instructions to work with the prescribing provider and explains the right to request a formulary exception.
Notice explains cost-sharing for the one-time transition supply (based on tier and Extra Help eligibility).
Customer service contact information and TTY number are provided for questions.

Denial Risk

Excluded or coverage-determined drugs

Excluded or coverage-determined drugs — not eligible for transition supply. Certain drugs are not eligible for transition or emergency supplies when they are excluded from Medicare Part D coverage or require a Part B vs Part D determination or are prescribed for non‑approved indications.

Weight loss drugs
Cosmetic drugs
Over-the-counter (OTC) drugs
Drugs requiring a Part B vs Part D coverage determination
Medicare-covered drugs prescribed for a non-approved indication

Key Definitions and Transition Periods

inv-08: Transition period — 90-day eligibility window

DefinitionThe first 90 days of eligibility for new members or the first 90 days after a formulary change in a new contract year during which temporary supplies may be provided.

Eligibility window90 days — applies to new enrollees and current members affected by formulary restrictions in the first 90 days of the new contract year.

Minimum retail supplyAt least 30 days of medication (unless the prescription is written for less).

IncludesPart D drugs on the formulary that require prior authorization or step therapy, and non-formulary Part D drugs when applicable.

PurposeTo allow temporary access to medications while prior authorization, step therapy, or exception requests are being processed.

inv-09: Long-term care transition — LTC multiple fills up to 31 days

DefinitionProvision in long-term care (LTC) settings allowing multiple fills as needed while authorizations or exceptions are pending, and emergency supplies during exception processing.

Minimum LTC supply per fillAt least 31 days of medication (unless the prescription is written for less).

Multiple fillsUCare will honor multiple fills as needed up to a 31-day supply in LTC settings.

Emergency LTC supply outside 90 daysIf a member in LTC is outside the 90-day transition window, UCare will still provide an emergency supply while an exception is being processed for at least 31 days.

IncludesPart D drugs on the formulary that require prior authorization or step therapy, and non-formulary Part D drugs when applicable.

Background

This policy is administrative and describes temporary access to Part D medications to prevent interruptions in therapy while coverage issues are resolved. It provides a process for issuing short-term or emergency supplies when members cannot immediately obtain their prescriptions during transitions such as new-member onboarding, formulary changes, level-of-care changes, or while prior authorizations and exceptions are pending. The policy clarifies that some drugs may not be eligible for transition if they are excluded from Medicare or require a Part B vs Part D coverage determination.