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Medicare Part D Transition Policy Update

January 14, 2011

Beginning January 1, 2011, many Medicare Part D beneficiaries will enter into a 90-day Transition Period. Part D plan sponsors are required by CMS to provide for an appropriate transition period for new enrollees prescribed Part D drugs that may not be on their plan’s formulary or included on the formulary but subject to certain limitations (e.g. prior authorization or step therapy). A Part D sponsor’s transition process is necessary with respect to: (1) the transition of new enrollees into prescription drug plans following the annual coordinated election period; (2) the transition of newly eligible Medicare beneficiaries from other coverage; (3) the transition of individuals who switch from one plan to another after the start of the contract year; (4) enrollees residing in LTC facilities; and (5) in some cases, current enrollees affected by formulary changes from one contract year to the next. In addition, sponsors are expected to expedite transitions to formulary drugs for enrollees who change treatment settings due to changes in level of care.

In order to address situations in which an individual beneficiary first presents at a participating pharmacy with a prescription for a drug that is not on the formulary, unaware of what is covered by the plan or of the sponsor’s exceptions process for providing access to Part D drugs that are not covered, Part D sponsors must have systems capabilities that allow them to provide a one time, temporary supply of non-formulary Part D drugs. This one-time fill for patients in the retail setting (up to three x 31 day supply fills, unless the prescription is written for less than 31 days for patients in long-term care facilities) is to accommodate the immediate needs of an enrollee, as well as to allow the sponsor and/or the enrollee sufficient time to work out with the prescriber an appropriate switch to a therapeutically equivalent medication or the completion of an exception request to maintain coverage of an existing drug based on medical necessity.

In addition to transition fills of non-formulary prescription, plan sponsors are required to provide each enrollee with a written transition notice, via U.S. first Class mail, within three business days of the temporary fill. New for the 2011 plan year, CMS is requiring that plan sponsors also “ensure that reasonable efforts are made to notify prescribers of enrollees who receive a transition notice after adjudication of a temporary fill”  (42 C.F.R.§423.120(b)(3)(v)). As a consequence of this new guidance from CMS (effective 1.1.2011)  BlueMedicareRx will  be sending via U.S mail a copy of the member’s transition notice (labeled ‘PRESCRIBER COPY” on the top of the notice) as well as a cover letter to the prescriber of record. We are supportive of CMS’ new directive and hope that you will find this additional information valuable in obtaining appropriate drug therapy for your patients in the BlueMedicareRx Part D program.

 

References:

1.    Anon. Medicare Prescription Drug Benefit Manual: Chapter 6 Part D Drugs and Formulary requirements, Section 30.4 Transition. CMS website: assessed on 12.30.10 @ http://www.cms.gov/PrescriptionDrugCovContra/Downloads/Chapter6.pdf.  

2.    Anon. Medicare.gov: The Official U.S. Government Website for Medicare.  CMS website: Accessed on 12.30.10 at http://www.medicare.gov/.

3.    Tudor, CG. Memo: Guidance on What Constitutes Reasonable Efforts to Notify Prescribers of Transition Fills. Center for Medicare. Distributed via HPMS on December 20, 2010.