Transition Policy

What can you do if a drug you are taking is not on the formulary or if the drug is restricted in some way? If your drug is not on the formulary or is restricted, here are things you can do:

  • You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply)
  • You can change to another drug
  • You can request an exception and ask Trillium Medicare Advantage to cover the drug

Under certain circumstances, in accordance with CMS requirements, Trillium Medicare Advantage can offer a temporary supply of a drug to you when your drug is not on the formulary or when it is restricted in some way. This temporary supply assists with the immediate need and allows you time to speak to your doctor about a different medication or dose which is covered within the plan guidelines or complete an exception request.

To be eligible for a temporary supply, you must meet BOTH of the two requirements below:

  1. The drug you have been taking:

    • Is no longer on the Trillium Medicare Advantage formulary OR
    • Was never on the Trillium Medicare Advantage formulary OR
    • The drug you have been taking is now restricted in some way

      (Chapter 5 in the Evidence of Coverage has more information).
  2. AND You must be in one of the situations described below:

    • For those members who were enrolled with Trillium Medicare Advantage last year and aren’t in a long-term care facility:
      • We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
    • For those members who are new to Trillium Medicare Advantage and aren’t in a long-term care facility:
      • We will cover a temporary supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
    • For those who are new to Trillium Medicare Advantage, and are residents in a long-term care facility:
      • We will cover a temporary supply of your drug during the first 90 days of your membership. The first supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days of your membership up to a maximum of a 98-day supply.
    • For those who have been a member of Trillium Medicare Advantage for more than 90 days, are a resident of a long-term care facility and need a supply right away:
      • We will cover one 31-day supply or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.  An exception or prior authorization should also be requested at the time the prescription is filled.

Additionally, throughout the plan year you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to:

  • Members who are discharged from a hospital or skilled-nursing facility to a home setting
  • Members who are admitted to a hospital or skilled-nursing facility from a home setting
  • Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy
  • Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit
  • Members who give up Hospice Status and go back to standard Medicare Part A and B coverage
  • Members discharged from psychiatric hospitals with highly individualized drug regimens

For these changes in treatment settings, we will cover as much as a 30-31-day temporary supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks.

There are other situations where you may be entitled to receive a temporary supply.  If you have questions or to ask for a temporary supply of a drug, call Member Services.

The cost-sharing for a temporary supply will never exceed the statutory maximum co-payment amounts for low-income subsidy (LIS) eligible enrollees.

After you get your Transition Fill

After you receive your temporary fill, you will receive a letter within three business days telling you what to do next.  The physician who prescribed the medication will also receive a copy of the letter.  When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:

Changing to another drug:

There may be other medications covered by Trillium Medicare Advantage that may work for you. You can call Member Services to ask for a list of covered drugs and share it with your provider to find a drug that might work for you.

Asking for an exception:

You or your provider can ask Trillium Medicare Advantage to make an exception or submit a request for coverage determination. For example, you can ask to cover a drug even though it is not on the Allwell formulary, or you can ask to cover the drug without limits.  Please see below chart for contact information for your plan coverage.

Drug Coverage Determination Form By mail:  By fax: By phone:

HMO SNP Drug Coverage Determination Form...Coming Soon

*You cannot use this form for Medicare non-covereddrugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).               

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Last Updated: 09302016
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