CASE FLASH: TRANSITION FILLS IN PART D PLANS

Mr. H is 54 and recently became eligible for Medicare due to a disability. Once he became eligible for Medicare, Mr. H enrolled in Original Medicare Parts A and B, as well as a Medicare Part D prescription drug plan. This month, Mr. H went to the pharmacy to get his diabetes medication, but was told by his pharmacist that his new Medicare Part D plan does not cover this particular medication. He would have to pay the full cost of the drug.

Mr. H called the Medicare Rights Center to ask a hotline counselor how he could get his new plan to cover his prescription. The hotline counselor explained that every Medicare Part D drug plan is required to have a “transition policy” to make sure that new members can access the medications they have been taking regularly. New members can use the “transition policy” during the first 90 days with the plan to get at least one 30-day supply of a medication, even if the medication is not covered by the plan or is covered with a restriction (such as requiring “prior authorization”). The hotline counselor instructed Mr. H to go back to the pharmacy to request that the pharmacist fill the prescription using the plan’s “transition fill policy.” The pharmacist would likely need to call the Part D plan to ask for the override code in order to bill it correctly.

The hotline counselor then warned Mr. H that a transition fill is only a temporary solution, and added that he should take action immediately to ensure that he would continue to get his prescription covered throughout the rest of the year. To do this, Mr. H would need to have his doctor write a letter to the Part D plan explaining why this particular drug is medically necessary for Mr. H, and formally asking the plan for an “exception” to the formulary.

Following the counselor’s advice, Mr. H had his pharmacist contact the Part D plan and was able to get the transition fill. A few days later, Mr. H contacted his doctor and asked her to write a letter to his Part D plan to get his medication covered for the rest of the year. Within 72 hours of receiving Mr. H’s doctor’s letter, the plan informed Mr. H and his doctor that it would continue to cover the medication for Mr. H for the remainder of the year. If Mr. H decides to stay in the same plan after the end of this year, he will need to have his doctor write another letter to the plan to continue to get the medication covered for next year.

-Adapted from: “ Case Flash: Transition Fills in Part D Plans”, MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 12, No. 1: January 13, 2009.

 

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