Transition Policies

CMS encouraged the PDPs to develop a transition policy for dual eligibles who are moving to a new plan that does not cover their current medication.  These transition policies are temporary solutions so that a person can continue their medications for 30 days.  This provides time for the beneficiary to look for another plan that does cover all of his or her medications, or to contact their doctor to determine if another medication could be substituted or to ask for help in requesting an exception.   

The purpose of the transition process is not simply to provide a temporary supply of non-formulary drugs during a certain period of time but, rather, to provide enrollees with sufficient time to work with their health care providers to switch to a therapeutically appropriate formulary alternative or to request a formulary exception on the grounds of medical necessity. At the same time, it is vital that enrollees be given clear guidance regarding how to proceed after a temporary fill is provided so that an appropriate and meaningful transition can be effectuated before the end of the transition period.

CMS has said to the plans that “until the transition is actually made, however, either through a switch to an appropriate formulary drug, or resolution of an exception request, continuation of drug coverage is necessary, other than for drugs not covered under Medicare Part D. Enrollees should not have to learn at the pharmacy about the need to obtain prior authorization for a drug or transition to a different drug; nor should they face delays at the pharmacy counter because needed transition actions, such as exception requests have not been resolved.”

For more information about what CMS is saying to the Part D plans about formulary transition policies, see this memo dated March 17th. Individuals experiencing problems should contact 1-800 MEDICARE (1-800-633-4227). CMS has also provided an updated fact sheet with tips for getting medications after the transition period.

Earlier this year CMS distributed three different documents to remind PDPs and pharmacists about the transition policy. Advocates can use these letters to help dual eligibles access needed medication.  The letters are:

1.  a transition policy reminder letter to PDP’s
2.  a pharmacist help letter guide them through the CMS resources
3.  a frequently asked questions for dual eligibles. 

CMS has provided scenarios of common problems and how they can be resolved. This document is at: www.cms.hhs.gov/partnerships/downloads/whatif1.pdf .  If individuals encounter situations not covered by these descriptions they should contact the CMS regional office for their state.  Click here for a list of the e-mails to the regional offices.