The Centers for Medicare and Medicaid Services (CMS) requires that sponsors of Medicare Part D prescription drug plans provide beneficiaries with access to transition supplies of needed medications to protect them from disruption and give adequate time to move over to a drug that is on a plan’s formulary (medication list), file a formulary exception request or, particularly for Low Income Subsidy (LIS) recipients, enroll in a different plan.
Transition rules apply to stand-alone Medicare Prescription Drug Plans (PDPs), Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs), and Medicare-Medicaid Managed Care Plans participating in the Dual Eligible Financial Alignment Demonstrations.
Transition rules are particularly important for low-income beneficiaries who were automatically reassigned to new plans, which may or may not cover their medications.
In addition, all plans change their formularies each year, so even people who remain in the same plan may find that their plan no longer covers their medications or has newly imposed utilization management requirements.
To assist advocates with transition issues, this fact sheet sets out the CMS minimum requirements for all plans.
For further information, contact Georgia Burke, firstname.lastname@example.org.