Drug Transition Policy
A transition refill, also called a transition fill, is a one-time, 30-day supply of a drug you’ve been taking that your plan doesn’t cover. Plans must provide a transition refill if one of these is true:
- You recently switched plans and your medication is not on your new plan’s covered drug list (formulary).
- Your plan dropped your medication from its formulary or added coverage restrictions for the new calendar year, such as prior authorization or step therapy requirements.
- You can get a transition refill up to 90 days after enrolling in a new plan or after your plan changes its coverage terms. Transition refills are only for drugs you were already taking. You can’t get one for a new prescription.
The pharmacy will tell you if you can get a transition refill when you go to refill your prescription. When you use your transition refill, your plan will send you a notice telling you that it’s temporary and explaining your options. You can only get one transition refill of your medication.
Call Member Services at 1-833-230-2020 (TTY: 711) to find out more. We are open 8 a.m. to 8 p.m. Monday through Friday, and from October 1 through March 31 we are open the same hours, seven days a week.
To be eligible for a temporary supply, you must meet the two requirements below:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan’s drug list.
- The drug you have been taking is now restricted in some way.
- You must be in one of the situations described below:
- For those members who are new or who were in the plan last year and aren’t in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
- For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away: We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
Long-Term Care Facility Members
Long-term care facility members receive up to a 31-day supply, unless the enrollee presents a prescription written for less than 31 days, and they are entitled to refills (up to a 31-day supply), as necessary, during the transition period (first 90 days on the plan, beginning on the enrollee’s effective date of coverage or when admitted into a qualified long-term care facility).
Additionally, institutionalized members are allowed a 31-day supply, when a qualifying level of care change has occurred, which affects the enrollee’s ability to obtain a Part D non-formulary drug, for example, when an enrollee’s Part A coverage expires. The CareSource Dual Advantage pharmacy benefits manager will verify the “level of care” change by confirming admission date of the member and the type of facility in which the member will reside.
Assisted living facilities, retirement homes or other non-skilled group homes are not deemed by CMS to be an approved institutional setting and thereby do not qualify for the long-term care transition protocols.
Request a Temporary Supply
To find out more about requesting a temporary supply, call Member Services at 1-833-230-2020 (TTY: 711). We are open 8 a.m. to 8 p.m. Monday through Friday, and from October 1 through March 31 we are open the same hours, seven days a week.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.