Transition drug refills

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A transition refill, also known as a transition fill, is typically a one-time, 30-day supply of a drug that Medicare drug plans must cover when you’re in a new plan or when your existing plan changes its coverage. Transition fills let you get temporary coverage for drugs that aren’t on your plan’s formulary or that have restrictions on them. (Your plan’s formulary is your plan’s list of covered drugs. Restrictions, such as step therapy or prior authorization, are rules that you have to follow before the plan will cover your drug.)

Transition fills aren’t for new prescriptions. You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage.

All Medicare Part D drug plans must cover transition fills. The rules apply to both Medicare Advantage plans that include drug coverage and Medicare stand-alone drug plans. When you use your transition fill, your plan must send you a written notice within three business days. The notice will tell you that the supply was temporary and that you should either change to a covered drug or file a request with the Part D plan (called an exception request) to ask for coverage.

The rules for transition fills are different depending on whether or not you live in a nursing home. The following situations describe when you can get a transition refill if you do not live in a nursing home and what action your plan must take.

1.  You are an existing member of a plan that is changing how it covers a Medicare-covered drug you have been taking.

  • If your plan is taking your drug off its formulary for the next calendar year for reasons other than safety, then the plan must either:
    • Help you complete the exceptions process (start an appeal) before January 1, or 
    • Help you switch to a similar drug that is on your plan’s formulary before January 1, or
    • Give you a 30-day transition fill within the first 90 days of the new calendar year along with a notice that your drug is no longer covered.
  • If your plan is adding step therapy or prior authorization to your drug for the next calendar year, then your plan must:
    • Help you complete the exceptions process (start an appeal) before January 1, or 
    • Help you switch to a similar drug that is on your plan’s formulary before January 1, or
    • Give you a 30-day transition fill without applying the restriction within the first 90 days of the calendar year along with a notice about the new restriction.

2.  You are new to a plan and the plan doesn’t cover a Medicare-covered drug you have been taking.

  • If it’s not covered because the drug isn’t on your new plan’s formulary, then your new plan must give you a 30-day transition fill within the first 90 days you’re enrolled in the plan. It must also give you a transition notice that says you’re using your transition fill and informs you of your appeal rights.
  • If your drug is on your new plan’s formulary but isn’t covered because it has step therapy or prior authorization restrictions, then your new plan must give you a 30-day transition fill without applying the restriction during the first 90 days you’re enrolled in the plan. It must also give you a transition notice that says you’re using your transition fill and informs you of your appeal rights.

When you get your transition fill, you should call your doctor right away to talk about switching to a drug that is on your plan’s formulary without restrictions. If no other drug will work for you, ask your doctor for help requesting an exception to your Medicare Part D drug plan’s formulary. Requesting an exception means to formally ask the plan to cover your drug.  

If you request a coverage exception but it has not been processed by the end of the 90-day transition fill period, your plan must provide more temporary refills until the exception is completed.

If you live in a nursing home and join a new Medicare drug plan that doesn’t cover your drugs or has restrictions on your drugs, then:

  • Your plan must cover all the refills you get within your first 90 days in the plan without prior authorization or step therapy restrictions. It must cover monthly or weekly refills of your medication during those first 90 days, depending on how refills of your drug are normally provided in your nursing home. You also get 90 days of transition coverage if your existing plan removes a drug you take from its formulary or puts restrictions on it.
  • You should request an exception to your plan’s formulary right away to ask the plan to cover the drug with no restrictions.
  • After your first 90 days in the plan, your plan must fill a 31-day emergency supply of your drugs if your exception request is still being processed.

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