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Vol. 15, Issue 2 – January 25 , 2016
What is a transition fill? Dear Marci, 

 

My stand-alone Part D prescription drug plan used to cover the medication I take, but it changed its coverage for 2016. My medication is no longer on the plan’s list of covered drugs. Is there a way I can get the medication I need?

–  Augustine (Melbourne, FL)

Dear Augustine,

You are entitled to a transition refill, or transition fill, which is a one-time, 30-day supply of a drug that Medicare drug plans must cover. Transition fills are for new plan members or for existing plan members whose drugs are no longer covered or are subject to new restrictions. Transition fills only apply to a drug you were taking before the plan stopped covering it or changed the way that it is covered.

In your case, you are eligible for a transition fill because your plan took the drug off its formulary, or list of covered drugs, for 2016. You will have up to 90 days from January 1, 2016, to request a transition fill. This timeframe also applies to beneficiaries whose plans added new restrictions to the drugs they take, such as prior authorization, quantity limit, or step therapy. Similarly, if you join a new plan and need a transition fill, you have up to 90 days after the first day you joined the plan to request and receive the transition fill.

To access your transition fill, your pharmacist may need to call your Part D plan. The pharmacist should say that they are requesting a transition fill and ask the plan to cover the drug without restrictions. The plan may give the pharmacist information about how to bill the plan correctly.

Once you get your transition fill, you should speak with your doctor about switching to a drug that is on your plan’s formulary without restrictions. If there is no other drug that will work for you, you and your doctor can request an exception to your Part D plan’s formulary. Requesting an exception means that you are formally asking the plan to cover your drug. If you request an exception and a determination is not made by the end of your transition fill period, your plan must provide more temporary refills until the exception request is addressed.

It is your right to access a transition fill as well as to file an exception request to try to get your prescription drug covered. Your doctor can be an important resource for helping you access the medications you need.

– Marci

 

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Need to Know
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