Medicare Part D Transition Process

The purpose of the policy is to ensure necessary continuity of treatment and to provide adequate time and transition process to introduce the member and their prescribing physician to the Community Care Alliance of Illinois Medicare Formulary.

The following is covered under the Transition Policy:

• Transition Timeframes
• Eligible members
• Applicable drugs
• Transition notices
• Level of care changes
• Emergency Supply for current members
• Transition extensions
• New prescriptions vs ongoing drug therapy
• Transition across contract years for current members
• Treatment for re-enrolled members

The policy also describes how transition benefits apply when in the following settings:

• Long Term Care (LTC)
• Retail Pharmacies
• Mail-Order Pharmacies

Transition Timeframes

Retail and Mail Order: New members or re-enrolled members to the plan may allow you to receive a 30 day transition supply (or greater if the packaging cannot be reduced, or less if the prescription is written for fewer days) of Part D eligible drugs. This can occur at any time within your first 90 days of coverage.

Long Term Care: You may be allowed a 31 day transition supply (unless prescription is written for fewer days) of eligible Part D drugs during the following times:

• Any time during the first 90 days of coverage and depending on how many days of medication are filled each time; you may get a 91-98 transition supply or 31 day supply per fill or greater if packaging cannot be reduced to a 31 day supply or less.
• If after the 90 day transition period has ended and if coverage determination is being processed; you may be able to get an emergency 31 day supply.

Eligible Members

If you are currently taking drugs that are not listed in the plan’s drug list (formulary) from one year to the next, you may be eligible for a transition fill if the following applies to you:

• New to the prescription plan at the start of the contract year
• Newly eligible for Medicare Part D of the contract year
• Switching from one Medicare Part D plan to another after January 1st in the contract year
• Affected by negative changes to the plan’s drug list from the previous to new contract year
• Living in an LTC setting

Applicable Drugs

You can receive eligible Part D drugs under the transition fill when:

• Drugs are not listed on your plan’s drug list
• On your plan’s drug list but in order for you to get the drug is limited (Example, prior authorization or step therapy)

Certain drugs may not be eligible for a transition supply at the pharmacy and therefore will require a review to determine if the drugs can be covered under the Part D plan.

Transition Notices

We will send written notice via U.S. mail to the member within three business days of adjudication of a temporary fill. The notice will include:

• An explanation of the temporary nature of the transition drug supply that a member has received;
• Instructions for working with the plan and the member’s prescriber to identify appropriate therapeutic alternatives that are on our formulary;
• An explanation of the member’s right to request a formulary exception; and
• A description of the procedures for requesting a formulary exception.

For Long Term Care transition fill for oral brand solids limited to a 14 days’ supply, a Transition Fill notice will be sent only after the first temporary fill.

Level of Care Changes

You may have changes that take you from one level of care setting to another. During the change, drugs may be prescribed that are not covered by the plan. If this happens, you and your doctor must go through the plan’s coverage determination process.

Transition Extensions

We will use Express Scripts Part D Services, on a case-by-case basis, will provide an extension of the transition period to accommodate members who continue to await resolution of a pending prior authorization or exception request. The extensions are available through the Pharmacy Help Desk or Customer Care and per your plan design.

New Prescription vs Ongoing Drug Therapy

The transition process is setup so that the distinction cannot be made between a brand-new prescriptions for a Non-Formulary Drug or an ongoing prescription for a Non-Formulary Drug at the point of sale, Express Scripts Part D Services, transition process will be applied to the prescription as if it is ongoing drug therapy.

Transition across Contract Years for Current Members

The following processes are options that we may request Express Scripts Part D Services to implement for renewing members:

• Use the advance notice of any formulary changes.
• Possible work to educate and transition current members on medications that will no longer be on the formulary in the new contract year or that will require prior authorization, step therapy or quantity limit utilization management edits in the new contract year.
• Encourage processing of formulary exceptions/prior authorizations prior to January 1 or a new contract year.
• Consistent with the transition fill process provided to new members, Express Scripts Part D services provides transition fill to renewing Beneficiaries during the first 90 days of the contract year with history of utilization of impacted drugs when those members have not been transitioned to a therapeutically equivalent formulary drug; or for whom formulary exceptions/prior authorizations are not processed prior to the new contract year. This applies to all renewing Beneficiaries including those residing in LTC facilities.

Treatment for Re-Enrolled Members

You may decide to leave one plan to enroll in a new plan or re-enroll in the original plan you had. If this happens, you would be considered as a new member and therefore eligible for transition benefits.