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January 8, 2025

Medicare Part D Transition Supply Policy

Avisery would like to remind professionals who assist Medicare beneficiaries about the Medicare Part D 30-Day Transition Supply policy. This policy can assist new enrollees in Medicare Part D plans, including Medicare Advantage plans that offer prescription drug coverage, to access a temporary supply of a prescription drug that is not on the plan’s formulary or that has utilization restrictions. Beneficiaries who remain in the same plan from one contract year to the next may also, under certain circumstances, be eligible for a transition supply of a drug that will no longer be covered by the plan.

Background

The Centers for Medicare and Medicaid Services (CMS) require stand-alone Part D and Medicare Advantage plans that include drug coverage (MA-PD) to offer newly enrolled beneficiaries a one-time 30-day transition supply of a beneficiary's existing prescription that is not on the new plan's formulary. A transition supply can be used anytime within the first 90 days of coverage with a Part D or MA-PD plan. Beneficiaries in long-term care facilities that are new to a plan are eligible to receive multiple fills for at least up to a 31-day supply within the first 90-days of coverage. Please note that the transition supply does not apply to Part D excluded drugs or drugs that are newly prescribed to a beneficiary during the first 90 days they are enrolled in the plan.

This policy can also be used for drugs that are on a plan’s formulary but have drug restrictions, such as prior authorization or step-therapy, that may not allow a beneficiary to immediately obtain their drug at a network pharmacy that works with the plan.

Plan members who are not new enrollees but who experience a negative formulary change from one year to the next may also be eligible to receive a transition supply if the plan did not work with them prior to the new year to find an equivalent drug that is on the plan’s formulary or to submit a formulary exception before the new coverage year began. 

What Happens When a Transition Supply is Filled

Once a Part D plan provides a transition supply, the plan is required to notify the individual in writing within three business days explaining that the drug in question is not on the plan’s formulary (or has drug restrictions) and that the supply was temporary. The temporary transition fill is intended to provide the member with enough time to either request a formulary exception from their plan or find a substitute drug that is on the plan’s formulary. 

A plan can charge no more for a transition fill than the same cost sharing amount that the plan would apply if a drug was approved through the formulary exception process (a cost sharing amount from one of the plan’s approved drug tiers). Beneficiaries eligible for the Extra Help program (also referred to as the Low-Income Subsidy or LIS) can be charged no more than the maximum Extra Help co-pay amount the beneficiary qualifies for.

To learn more about the Medicare Part D Transition Supply policy, visit: 

National Council on Aging, Medicare Part D Transition Supply Policy: https://www.ncoa.org/article/medicare-part-d-transition-policy

Center for Medicare and Medicaid Services, Medicare Prescription Drug Benefit Manual, Chapter 6: https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/part-d-benefits-manual-chapter-6.pdf (section 30.4) 

CMS Information for Part D Sponsors on Requirement for a Transition Process: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/TransitionProcess_031605.pdf  

If you have any questions or need help counseling older adults and adults with disabilities on Medicare, Medicaid, or other health benefits programs, please reach out to Avisery at avisery@ageoptions.org or 708-628-3440.

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