Medicare Part D Medication Transition Policy
HealthPartners medication transition policy will provide transitional medications to:
- New enrollees to HealthPartners Medicare Part D plans as of January 1st following the Annual Enrollment Period.
- Newly eligible Medicare beneficiaries from other coverage.
- Individuals who switch from one plan to another after January 1st.
- Enrollees residing in long-term care (LTC) facilities.
- Enrollees residing in long-term care (LTC) facilities who have changes in level of care. For example, those entering an LTC facility or being discharged from a hospital. In this situation, early refills will be granted due to change in their level of care, when appropriate.
- Continuing enrollees affected by formulary changes from one contract year to the next.
HealthPartners will provide a one-time, temporary supply of non-formulary Part D drugs in order to accommodate the immediate needs of an enrollee. Non-formulary drugs include (1) Part D drugs that are not on the HealthPartners formulary; (2) drugs previously approved for coverage under an exception once the exception expires; and (3) Part D drugs that are on HealthPartners formulary but require prior authorization or step therapy, or that have an approved quantity limit lower than the beneficiary’s current dose, under HealthPartners utilization management rules.
This transition policy provides a one-time temporary 30-day fill at the retail setting (unless the enrollee presents a prescription written for less than 30 days) anytime during the first 90 days of the beneficiary’s enrollment in a plan, beginning on the enrollee’s effective date of coverage, or the first 90 days of the contract year for continuing enrollees. Thirty days allows the plan and/or the enrollee sufficient time to work with the prescriber to either switch to a therapeutically equivalent medication on HealthPartners formulary or complete an exception request to maintain the coverage of the non-formulary drug based upon medical necessity reasons.
The cost sharing for the one-time transition will never exceed the enrollee’s maximum copayment or coinsurance amounts and includes enrollee’s low income subsidy amounts, if eligible. Cost sharing will be based upon the appropriate tier the non-formulary drug labeled, meaning brand drugs will process under the brand copay when appropriate.
HealthPartners will send written notice to the enrollee within three business days of the transition fill indicating:
- An explanation of the temporary nature of the transition supply an enrollee has received.
- Instructions for working with the HealthPartners and the enrollee’s prescriber to identify therapeutic alternatives, when available and appropriate.
- An explanation of the enrollee’s right to request a formulary exception.
- Description of the procedures for requesting a formulary exception.
Enrollees residing in a LTC setting will receive a temporary supply of 91 to 98 days in increments of up to 31-day fills, with multiple fills as necessary, during the first 90 days of the beneficiary’s enrollment with HealthPartners. In addition, HealthPartners will provide a one-time 31-day emergency supply of non-formulary drugs while an exception is being processed.
For more information
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or visit medicare.gov.
Need a directory?
If you would like a Provider/Pharmacy Directory mailed to you call Member Services.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
HealthPartners MSHO is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. HealthPartners Freedom is a Cost plan with a Medicare contract. Enrollment in HealthPartners depends on contract renewal.
Last updated October 2016