All Medicare drug plans, called Part D plans, must offer transition refills for new plan members or existing members whose drugs are no longer covered or are subject to new restrictions. Transition refills allow beneficiaries to get temporary coverage if a plan changed the coverage rules — for example, the plan removes a drug from its formulary (covered list of drugs) — or if a beneficiary joins a new plan. Your clients have 90 days after they join a plan to get a transition refill; or, if their plan changed the coverage rules for the new calendar, they have 90 days from the start of the year.
The new year is a good time to know about transition refills, because many of your clients could face a financial surprise with their first trip to the pharmacy for the calendar year and turn to you for advice.
Many may have just switched plans during Medicare’s Open Enrollment Period — Oct. 15 through Dec. 7 each year — but do not know the details about the plan. For example, their previous plan may have had a $400 deductible, but they discover at the pharmacy counter that they owe more upfront because of a higher deductible. Sometimes, a plan can require that a brand name medication needs a prior authorization from the doctor or that a patient first try other medications before stepping up to more expensive drugs — a process called “step therapy.” Even if patients don’t switch plans, their insurer may make switches that affect their budgets. For example, an insurance plan may remove a prescription from its formulary, meaning the drug is no longer covered.
Medicare’s transition refill requirement makes sure that your clients’ prescriptions are not disrupted by such insurance company requirements. But if clients ask you about transition refills, make sure they take action immediately to change the medication to a covered alternative, complete the step therapy or prior authorization paperwork, or complete a medication exception request form with the help of their doctor. If no action is taken, the plan will not cover the medication, and after their 30-day supply is exhausted, they will be left paying the full cost of the medication.
