We provide a transition process consistent with 42 CFR §423.120(b)(3), which deals with access to covered prescription drugs under Medicare Part D.
The process includes a written description of how enrollees whose current drug therapies may not be included in the 2022 HAP covered drug list (PDF) or the 2023 HAP covered drug list (PDF), also known as a formulary, may receive a temporary supply of a nonformulary drug, as well as Part D drugs that are on the formulary but require prior authorization, step therapy or are subject to quantity limits under the HAP Medicare utilization management rules.
A meaningful transition period allows sufficient time for members to work with their health care provider to select an appropriate formulary alternative or to request a formulary exception based on medical necessity.
Transition policy eligibility
The transition policy applies to:
- New enrollees into prescription drug plans at the beginning of a contract year
- The transition of newly eligible Medicare beneficiaries from other coverage at the beginning of a contract year
- The transition of individuals who switch from one plan to another after the beginning of a contract year
- Enrollees residing in long-term care facilities
- Current enrollees affected by formulary changes from one contract year to the next
Transition policy facts
The following information applies to members who make use of our transition policy:
Transition fills in the outpatient (retail) setting
Transition fills in the long-term care setting
Emergency supplies and level of care changes
Transitions across contract years
Cost sharing for transition fill