Medicare Part D Transition Scenarios
Following are transition scenarios for Medicare recipients and the rules that apply for each scenario.
- New drug plan enrollees, newly eligible Medicare beneficiaries, and individuals who switch Medicare Part D plans
Plans must provide a temporary 30-day refill of non-formulary drugs if the refill is requested within the transition period (the first 90 days of coverage).
Plans must provide a 31-day refill and must honor remaining refills of non-formulary Part D drugs.
- Enrollees remaining on the same plan whose drug has been removed from the formulary list or who had an exception granted in 2007 that will not be extended into 2008
After enrollees receive their Annual Notice of Change on Oct. 31, plans must either:
- Provide a temporary supply of the requested prescription drug after Jan. 1, 2008, and notify enrollees that they must switch to a formulary drug or request an exception to continue taking the requested drug
- Transition enrollees to a formulary drug prior to Jan. 1, 2008
- Enrollees who request an exception and are not issued a decision by the end of the transition period
Plans should make arrangements to continue providing requested drugs on a case-by-case basis until a decision is made.
- Enrollees who remain on the same plan and had an exception granted in 2007
Plans have the option of “honoring” exceptions granted in 2007 beyond the end of the plan year.
If a plan is not going to continue to honor the exception, it must either:
- Notify the enrollee in writing at least 60 days before the end of the 2007 plan year and offer to process a prospective exception request for the 2008 plan year
- Provide the enrollee with a temporary supply of the requested prescription drug at the beginning of 2008 and notify the enrollee that they must switch drugs or apply for an exception.
- Enrollees who remain in same plan and are using a drug with a prior authorization requirement that is expiring
Before the beginning of the new plan year, enrollees may attempt to satisfy the pre-authorization requirement by requesting a coverage determination or by requesting a formulary exception if they cannot satisfy the pre-authorization requirement.
- Current enrollees who are receiving level-of-care changes
CMS encourages, but does not require, plans to allow for transition supplies to be provided to current enrollees with level-of-care changes outside of the transition period. Beneficiaries and providers should be aware of plan exceptions and appeals processes.
- Current enrollees entering long-term care settings from other care settings
These enrollees will be provided emergency supplies of non-formulary drugs. The transition supply is not limited to initial enrollment.
- Current enrollees in a long-term care setting requiring an emergency supply of a non-formulary drug
Once an enrollee in a long-term care setting is outside the transition period, the plan must still provide an emergency supply of at least 31 days of non-formulary Part D drugs while an exception is being processed.
Last Updated: 8/12/2008