There are specific rules in place to protect Medicare recipients when transitioning from one Medicare Part D program to another (and when other changes take place). The Center for Medicare and Medicaid Services (CMS) wants to protect Medicare recipients from disruption in medications and ensure sufficient time to make arrangements when transitioning to new plans or when a plan’s formulary changes.
These transition rules especially help low-income beneficiaries who are automatically assigned to plans and may need time to choose a new plan, file an exception request or transition to a new drug. Many plans have formulary changes from year to year, so this transition assistance is useful for any recipients who are experiencing changes. There can also be potential disruptions when someone is changing levels of care (moving into or out of a nursing facility, going on to hospice, etc.). These protections are good news for Medicare recipients and the advocates that help them!
Here are some specifics about the rules:
- Plans must provide a one-time 30 day supply of an ongoing medication during the 1st 90 days of coverage (applies to both new members and existing members when there’s a formulary change; applies to drugs not on the formulary and those subject to utilization management controls).
- Plans must mail 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. The notice must be mailed within 3 business days of the temporary fill.
- Residents in long-term care facilities get further protections: Plans must provide a 31 day supply during the first 90 days. Plans must honor multiple 31 day fills during the first 90 days.
- For Medicare recipients changing status (moving to a long-term care facility, being discharged, etc.): Early refill edits may not be used to deny an enrollee access to a refill upon admission or discharge from a facility. For members leaving facilities, plans should permit fills of prescriptions in the week before discharge to avoid gaps or delays
Medicare and the various Part D plans can be confusing for recipients and families. As your patient advocate, Aging Wisely is here to help with key information, resources and individualized assistance. Contact us today at 727-447-5845 for patient advocacy and Medicare/Medicaid assistance. We can help with a wide range of issues related to Florida Medicare and Medicaid as well as other benefits like Veteran’s benefits and state-specific programs.
Ensuring your care continuity and well-being is what we do!