Transition drug refills

A transition refill, also known as a transition fill, is typically a one-time, 30-day supply of a drug that you were taking:

• Before switching to a different  Part D Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. plan (either stand-alone or through a  Medicare Advantage Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan)
• Or, before your current plan changed its coverage at the start of a new calendar year

Transition refills let you get temporary coverage for drugs that are not on your plan’s formulary formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. or that have certain coverage restrictions coverage restrictions Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to limit their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy. (such as prior authorization prior authorization Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by Part D plans and Medicare Advantage Plans. If a service or drug requires prior authorization, you must first get approval from the plan for it to be covered. If you fail to get prior authorization before you get the service or drug, your plan generally will not cover it. or step therapy step therapy Step therapy is a restriction placed on drug coverage by Part D plans and Medicare Advantage Plans. Before your plan will cover a drug, you must first try a different or less expensive drug that treats your condition to see if it will be effective for you. ).

Transition refills are not 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.

When can you get a transition fill?

The following situations describe when you can get a transition refill if you do not live in a nursing home (there are different rules for transition refills for those living in nursing homes):

1. Your current plan is changing how it covers a Medicare-covered drug you have been taking.

• If your plan is taking your drug off its formulary or adding a coverage restriction for the next calendar year for reasons other than safety, the plan must either:
  • Help you switch to a similar drug that is on your plan’s formulary before January 1
  • Or, help you file an  Exception Request Exception Request An exception request is a formal written request to your Part D plan asking that it pay for a drug you need. For example, you can file an exception request to pay for a drug that is not on the plan’s list of covered drugs (formulary), or you can ask the plan to lower the cost of an expensive drug on the formulary (see Tiering Exception). 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 about the new coverage policy.

2. Your new plan does not cover a Medicare-covered drug you have been taking.

• If a drug you have been taking is not on your new plan’s formulary, this plan must give you a 30-day transition refill within the first 90 days of your Enrollment Enrollment Enrollment is joining Original Medicare or becoming a member of a Medicare Advantage Plan or Part D plan. . It must also give you a notice explaining that your transition refill is temporary and informing you of your appeal rights.
• If a drug you have been taking is on your new plan’s formulary but with a coverage restriction, this plan must give you a 30-day transition refill free from any restriction within the first 90 days of your enrollment. It must also give you a notice explaining that your transition refill is temporary and informing you of your appeal rights.
• In both of the above cases, if a drug you have been taking is not on your new plan’s formulary, be sure to see whether there is a similar drug that is covered by your plan (check with your doctor about possible alternatives) and, if not, to file an exception request. (If your request is denied, you have the right to appeal.)

Note: If you file an exception request and your plan does not process it by the end of your 90-day transition refill period, your plan must provide additional temporary refills until the exception is completed.

Remember: All stand-alone Part D plans and Medicare Advantage Plans that offer drug coverage must provide transition fills in the above cases. 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 an exception request with the plan.