A Part D transition happens when you have a change in the prescription drug list you use. A change can be when you enroll in a new plan or your current plan makes yearly drug list updates that affect you in a negative way. These negative changes can be when we remove items from our drug list or change the step therapy or prior authorization requirements on drugs you currently take.

Part D Transition: Everything you need to know

Part D transition applies to you when...

  • You are a new Blue Cross of Idaho Medicare Advantage member who enrolls in a plan with prescription drug coverage
  • You are new to Medicare or recently eligible for Part D prescription drug coverage
  • You reside in a long-term care facility
  • You are a current Blue Cross of Idaho Medicare Advantage member and you change from one of our plans to another
  • You are a current Blue Cross of Idaho member who has a negative impact from our yearly drug list changes. Changes can include when we remove medications and/or add prior authorization or step therapy requirements to drugs on our list.

How does Part D transition work?

The transition period for current members happens within the first 90-days of any yearly drug list changes. During this time, you can get a one-month supply of prescriptions that we remove from our drug list, have new step therapy or prior authorization requirements, or  change quantity limits. Any current prior authorizations you have remain effective through their expiration date.

After you receive a temporary one-month supply, you should speak with your provider about formulary alternatives, or requesting a formulary exception. We will send you information about the next year’s plan and drug list changes in the fall of each year.

New members have a 90-day transition period after they enroll in our plan. During this time, you may obtain a one-month supply of your prescriptions that are not on our drug list, have a step therapy or prior authorization requirements, or quantity limits. After you receive a temporary one-month supply, you should speak with your provider about formulary alternatives, or requesting an authorization or exception.

Within the first 90-days of moving to a long-term care facility, you can receive a one-month supply transition fill. After 90-days you may also be able to get a 31-day emergency supply every 30 days if a drug list exception or a prior authorization request is pending. Even if it’s too soon, you can refill your prescriptions when you move into or out of a long-term care facility.

How much will you pay?

What you pay during a transition period depends on the tier level of the drug, if the drug is not on our list you pay the cost of our non-drug list exception tier. Members who qualify for assistance pay an amount pre-determined by their level of assistance.

What happens when you need a refill?

We mail you a letter within three days after receiving your transition supply of drugs. The letter explains how you can request an exception and encourages you to discuss your medications with your provider. Remember to bring your new drug list when you see your provider. We may also let your provider know about your transition supply of drugs.

Drugs not eligible for Part D transition include…

  • Medicare Part B drugs or drugs excluded from Medicare Part D coverage
  • Drugs that need prior authorization to determine if they are covered under Medicare Part B or Part D
  • Drugs the Food and Drug Administration (FDA) has safety concerns about. (We will cover these drugs if we have an existing prior authorization in place.)

We may not process some transition drug supplies because the FDA recommended dosage or quantity limit is less than what your provider prescribed. Your pharmacist may reduce what you get to the FDA limit in order to give you time to talk to your provider about another drug or a formulary exception.

What happens when your level of care changes?

When you have a change in your level of care, like admission to a long-term care facility, you may need more medication. Requests for more medication may be denied if you ask for a refill too soon. If this happens, your pharmacy can ask us to override the denial in order to refill your prescription.

Can you get coverage for long-term care emergency supplies of non-list drugs?

We cover emergency supplies of non-list Part D drugs if you are outside your 90-day transition period and you are living in a long-term care facility. You can get a 31-day supply or the total amount of the medicine prescribed, whichever is less. We suggest you use the time of your emergency supply to ask for an exception.

How can you request a drug list exception?

You should first ask your provider to help you with an exception. They can call our pharmacy benefits administrator using the number on the back of your prescription ID card. A decision about your request is made within 72 hours or less. If your provider believes your health is at risk by waiting 72 hours, they can ask for an expedited exception and a decision is made within 24 hours or less. You have the right to an appeal if your exception request is denied. You or your provider can get prior authorization and exception forms on this website or the provider portal (link takes you away from the medicare website), or by calling us at 1-855-479-3661, TTY users can call 711. We are available 24 hours a day, seven days a week.

last update 10/1/2019