1. health and fitness
2. drugs

 Corporate Integrated Health
Management Policy
Title
Number
Current
Effective Date
Original
Effective Date
Replaces
Cross
Reference
Medicare Part D Transition – CY 2015
CP.IHM.PH.006.v1.1
January 1, 2015
Purpose
To ensure compliance with 42 CFR 423.120 (b) (3) regarding providing an appropriate
transition process for members prescribed Part D drugs that are not on the plan’s
formulary or Part D drugs on the formulary but require prior authorization or step
therapy.
Scope
Applies to PREMERA and its subsidiaries and affiliates (“Premera” or the “Company”)
and first tier, downstream and related entities for Medicare Advantage members with a
prescription drug (Part D) benefit.
Policy
In compliance with CFR 423.120 (b) (3), Premera Blue Cross Medicare Advantage Plans
(PBC) will maintain an appropriate transition process that includes a written description
of how, for members whose current drug therapies may not be included in their new Part
D plan’s formulary, it will effectuate a meaningful transition for: (1) the transition of
new members into the prescription drug plan at the beginning of the contract year; (2) the
transition of newly eligible Medicare members from other coverage at the beginning of a
contract year; (3) the transition of individuals who switch from one plan to another after
the start of the contract year; (4) members residing in long-term care (LTC) facilities;
and (5) in some cases, current members affected by formulary changes from one contract
year to the next. Transition supplies will be provided to allow the member and provider
time to discuss alternatives and/or submit documentation for prior authorization review.
05/30/13
CP.IHM.PH.006.v1.0
N/A
The transition policy will apply to non-formulary drugs, meaning both: (1) Part D drugs
that are not on the formulary, and (2) Part D drugs that are on the formulary but require
prior authorization or step therapy under the PBC utilization management rules. PBC
will ensure procedures for medical review of non-formulary drug requests and when
appropriate, a process for switching new Part D plan enrollees to therapeutically
appropriate formulary alternatives failing an affirmative medical necessity determination.
At point-of-service if PBC is not able to distinguish between a brand new non-formulary
drug and an ongoing prescription for a non-formulary drug then both will be treated the
same in the transition process. If a prescription is dispensed for less than the written
amount due to a plan edit, such as quantity limits for safety purposes or drug utilization
edits based on approved product labeling, PBC will provide refills for that transition
supply.
After members receive their Annual Notice of Change (ANOC) material, PBC will
effectuate an appropriate and meaningful transition for current members whose drugs are
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no longer on the formulary or have had new utilization management (UM) edits applied,
by providing a transition process that is consistent with the transition process required for
new members. PBC will provide a temporary supply of the Part D drug, if not medically
contraindicated, and provide the members with a notice that they must either switch to an
appropriate formulary drug or request an exception or coverage determination. If a
member enrolls with PBC with an effective date of either November 1 or December 1
and requires access to a transition supply, PBC will extend the transition policy across
the contact years.
IMPLEMENTATION:
PBC claims processing system capabilities will allow a one time, temporary supply of
non-formulary Part D drugs, as described above, to accommodate the immediate needs of
a member as well as to allow PBC and/or members time to work with the prescribing
provider to switch to an appropriate therapeutically equivalent Part D drug or to
complete an exception request to maintain coverage of an existing drug based on medical
necessity.
In order to assure that new members are able to leave a pharmacy with a temporary
supply of non-formulary Part D drugs without unnecessary delays, PBC will utilize
claims messaging that provides the pharmacy with a prior authorization code that can be
used at point-of-service to override step-therapy and prior authorization edits during
transition except for edits that are in place: (1) to determine Part B vs. Part D coverage;
(2) to prevent coverage of non-part D drugs (i.e. excluded drugs); and (3) to promote safe
utilization of a Part D drug (e.g., quantity limits based on FDA maximum recommended
daily dose; early refill edits).
PBC cost-sharing for a temporary supply of drugs provided under the transition process
will never exceed the statutory maximum co-payment amounts for low-income subsidy
(LIS) eligible enrollees. For non-LIS enrollees, PBC charges the same cost sharing for
non-formulary Part D drugs provided during the transition that would apply for nonformulary drugs approved through a formulary exception in accordance with §
423.578(b) and the same cost sharing for formulary drugs subject to utilization
management edits provided during the transition that would apply once the utilization
management criteria are met.
For members whose transition period has expired, this policy also establishes drug
classes in situations which would allow members to continue established therapy upon
prior authorization review request (non-formulary, prior authorization, step-therapy and
quantity limit).
PBC will send a written notice via U.S. First Class mail to each member within three (3)
business days of a temporary transition fill. The notice will include the following
elements: (1) an explanation that the transition supply provided is temporary and may not
be refilled unless a formulary exception is approved; (2) instructions for the member to
work with PBC and their prescriber to identify appropriate therapeutic alternatives that
are on the formulary; (3) an explanation of the member’s right to request a formulary
exception, and the member’s right to request an appeal if PBC issues an unfavorable
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decision; and (4) a description of the procedure for requesting a formulary exception. For
long-term care residents dispensed multiple supplies of a Part D drug in increments of 14
days or less, the written notice will be provided within 3 business days after adjudication
of the first temporary fill. PBC will use the Centers for Medicare and Medicaid Services
(CMS) model transition letter via the file-and-use process or submit a non-model
Transition Notice to CMS for 45 day marketing review. PBC will also make reasonable
attempts to notify prescribers of affected enrollees who receive a transition notice.
PBC will provide point-of-sale notification to pharmacists, so that they can notify
members about transition supplies, using current billing transaction response claims
messaging following National Council for Prescription Drug Programs (NCPDP) 5.1
standards. When alternative transactional coding is implemented in a new version of the
HIPAA standard, PBC will implement the appropriate system changes to incorporate any
new additional messaging approved by the industry through NCPDP.
Information regarding PBC transition is provided to members in pre-enrollment
marketing materials, post-enrollment materials and website. PBC will make the transition
policy available to members on our website that will also allow CMS to establish a link
to the policy from the Medicare Prescription Drug Plan Finder website.
PBC prior authorization or exception request forms are available upon request to both
members and prescribing physicians in a variety of mechanisms that include mail, fax,
email, and on the PBC website.
PROCEDURE:
For patients using retail pharmacies:
1. For new members, PBC transition policy will provide a 30-day fill (unless the
prescription is written for less than 30 days), with multiple refills as necessary for up
to a 90 day supply during the first 90 days of a members enrollment with PBC,
beginning on the members effective date of coverage.
2. An enrollee’s transition period will be extended as needed on a case-by-case basis to
the extent that their exception request or appeal has not been processed by the end of
the minimum transition period. Until the transition is made, through a switch to an
appropriate formulary drug, or a decision is made regarding an exception request,
continuation of coverage is necessary unless the drug is not covered under Part D.
3. This temporary transition supply does not apply to CMS restricted drug categories
and excluded drugs. PBC will not cover these drugs during the transition. The
following are examples of commonly excluded categories not covered under
Medicare Part D:
• cough and cold preparations
• erectile dysfunction (ED) drugs (Viagra, Cialis, Levitra, and Caverject)
• vitamins, except prenatal vitamins
• over-the-counter (OTC) drugs
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For patients residing in a Long-Term Care Facility (as defined by CMS)
In the long-term care setting: (1) the transition policy will provide for a 98 day fill
consistent with the dispensing increment (unless the prescription is written for less), with
refills provided if needed during the first 90 days of a beneficiary’s enrollment in the
plan, beginning on the enrollee’s effective date of coverage; (2) after the transition period
has expired, the transition policy provides for a 34-day emergency supply of nonformulary Part D drugs (unless the enrollee presents with a prescription written for less
than 34 days) while an exception or prior authorization is requested; and (3) for enrollees
being admitted to or discharged from an LTC facility, early refills are not used to limit
appropriate and necessary access to their Part D benefit, and such enrollees are allowed
to access a refill upon admission or discharge.
1. This temporary transition supply does not apply to CMS restricted drug categories
and excluded drugs. PBC will not cover these drugs during the transition. The
following are examples of commonly excluded categories not covered under
Medicare Part D:
• cough and cold preparations
• erectile dysfunction (ED) drugs (Viagra, Cialis, Levitra, and Caverject)
• vitamins, except prenatal vitamins
• over-the-counter (OTC) drugs
Post New Member Transition Continuation of Therapy:
CRITERIA:
1. The medication was filled during the new member transition period.
AND one of the following:
2. The medication is in one of the following CMS protected drug classes.
• Anticonvulsants
• Antidepressants
• Antipsychotics
• Anti-HIV
• Immune Suppressants
• Antineoplastics (Oncology)
3. The medication falls into one of the following USPDI drug classes:
• Antiarrythmic Agents
• Antiglaucoma Agents
4. Medical rationale that it is unsafe for the member to change to a preferred
alternative.
Violations of
Policy
Violations of this policy may be grounds for disciplinary action. The level of discipline is
at the discretion of the Company, and may include any of the following: (1) verbal
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Process
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Regulations &
Standards
warning; (2) written warning; (3) suspension; (4) termination; and (5) restitution.
Any exception to this Policy must be approved in advance by the VP, Pharmacy,
Contracting and Consulting.
References:
1.
Medicare Prescription Benefit Drug Manual, Chapter 6- Part D Drugs
and Formulary Requirements, Section 30.4-Transition, Rev.10, 02-19-10
2.
42 CFR 423.120 (b)(3)
Controls
The Compliance & Ethics Department and Pharmacy Department are responsible for
ensuring that Premera is in compliance with this Policy through routine audits of
transition fills.
Policy Owner
Chad Murphy, VP, Pharmacy, Contracting and Consulting
Contact
Any questions regarding the contents of this Policy or its application should be directed
to Customer Service at 1-888-850-8526. TTY users should call 711.
08/04/14; 07/08/14; 05/13/14; 05/30/13
Approval
Dates
Approval
IHM Programs Committee
Print Name
Chelle Moat, MD, Chair
Signature
Committee approval on file
Date
05/13/14
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