As over two million low-income Medicare beneficiaries nationwide and close to 500,000 beneficiaries statewide were automatically transferred to a new benchmark plan for 2008, and as many more beneficiaries switched plans on their own, accessing their required drugs in their new plans may well present challenges. New plan formularies, prior authorization requirements, and glitches in enrollment information may all cause some problems at the pharmacy counter.
To protect beneficiaries and make sure they have continued, seamless access to their needed prescriptions, each Part D plan must have a transition policy that provides beneficiaries with at least a 30-day supply of their medications within the first 90 days of their plan membership, even if not at the beginning of the plan year. These requirements mandated by Centers for Medicare and Medicaid Services (CMS) give beneficiaries time to find an alternate drug on their new plan’s formulary, request an exception or appeal a coverage determination, or, if they have the low-income subsidy (LIS), apply for a new plan. Also, as this policy applies to the first 90 days of a person’s membership, a beneficiary, for example, who refilled her prescription near the end of her coverage in her previous plan, can access this right when she goes to refill her medication again 60 days into her new coverage.
Outlined below are CMS’ minimum transition requirements, as summarized in a recent National Senior Citizens Law Center (NSCLC) document. This NSCLC document also has a chart that reviews the 15 California PDP plans that were benchmark plans in 2007 and/or are benchmark plans in 2008. The chart notes:
- any transition policy improvements over CMS’ minimum requirements,
- additional access to drugs with level of care transitions (such as from the hospital into the community), and
- website links to each plan’s transition policy.
View this NSCLC document online.
CMS Minimum Transition Policy Requirements:
All Part D plans must have transition policies to ensure that beneficiaries who are stabilized on a medication are not left without coverage in situations:
- When they are moving to a new plan, including a plan within the same sponsor organization that does not cover their current drug.
- When the plan in which they are currently enrolled drops coverage of that drug for the new plan year.
- When they experience a change in level of care, such as moving to or from a skilled nursing facility or moving from a hospital into the community.
For all enrollees, plans must:
- Provide a 30-day supply (unless a lesser amount is prescribed) of an ongoing medication within the first 90 days of plan membership.
- Covers drugs not on formulary and those subject to utilization management controls. (Note: If a patient presents a prescription for 30 pills, and the plan limits dosage to, for example, 14 pills, the plan may dispense 14 pills but must provide refills until the 30-day transition supply is met. If the plan normally requires prior authorization from a doctor before covering the drug, it must provide the 30-day supply without prior authorization.)
- Applies to the beneficiary’s first 90 days enrolled in plan, even if not at the beginning of the plan year. For example, a beneficiary who is newly eligible for Medicare and enrolls in a Part D plan effective April 1 would have a transition period until June 29.
- Applies both to new members and to continuing members when a plan has changed its formulary.
- Transition requirements do not apply to non-Part D drugs.
- Mail the beneficiary a written notice explaining that the transition supply is temporary, including instructions for identifying appropriate substitutes, notice of the right to request a formulary exception, and instructions on how to file an exception request.
Enrollees residing in a long-term care (LTC) facility or other institution have additional protections. For such enrollees, plans must:
- Provide a 31-day supply during the first 90 days of plan membership.
- Honor multiple 31-day fills during the first 90 days of plan membership.
- For a prescription requested after the first 90 days of membership, provide a 31-day emergency supply to allow time for an exception to be processed. (Note: this LTC requirement covers new prescriptions.)
All enrollees, including those experiencing a change in status e.g., moving from an acute care hospital to the community or into or out of a long-term care institution, may also have additional protections: These ‘protections’ are not required by CMS, but rather ‘strongly encouraged.’
- Extension of transition supplies on a case-by case basis until an “appropriate and meaningful transition can be effectuated.”
- Until that transition is actually made, however, either through a switch to an appropriate formulary drug, or decision of an exception request, plans are strongly encouraged to continue providing transition drug supplies.
For more information on CMS’ transition requirements for plans, see Chapter 6 of the Medicare Part D Manual at 30.4.