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What is Part D transition and how does it affect me?

Part D transition happens when either you have a change in you prescription drug formulary, by enrolling in a new plan, or your current plan makes an annual formulary change that affects you in a negative way.  

Your transition will occur within the first 90 days of enrolling in a Blue Cross of Idaho Medicare Advantage plan, or for current members, within the first 90 days of our annual drug formulary changes, but only if the changes affect you in a negative way.

How do I know if Part D transition applies to me?

You are eligible for transition if:

  • You are a new to Blue Cross of Idaho’s Medicare Advantage plans
  • You are newly enrolled in or newly eligible for Part D prescription drug coverage
  • You are a current Blue Cross of Idaho Medicare Advantage member, but change from one plan to another
  • You are a current member who is affected by annual formulary changes such as removal of your medication from the formulary, the addition of prior authorization requirements or step therapy.

How does Part D transition work?

For new members: Within the first 90 days of enrolling, you can receive a one-time, 30-day supply of your prescriptions that may not be on the formulary or that require step therapy or prior authorization. Use the time you get with these one-time fills to talk to your provider about alternatives or to request a formulary exception

For current members: Within the first 90 days of a new year, you can receive a one-time, 30-day supply of your prescriptions that may no longer be on the formulary or that require new step therapy or new prior authorization. Use the time you get with these one-time fills to talk to your provider about alternatives or to request a formulary exception

Current members receive notification of plan and formulary changes for the upcoming year in their Annual Notice of Changes (ANOC) that arrives in fall.

For current members with medication requiring prior authorization, your prior authorization remains effective until the expiration date, if that date carries over from one year to the next.

New and current members in long-term care facilities can receive a 31-day supply and up to a 98-day supply in their first 90 days.

What happens when I need another refill?

After you get a transition supply, we send you information on how to request a formulary exception and suggest that you discuss your medications with your provider. We may even notify your provider of your transition supply. When discussing medication changes with your provider, be sure to bring a copy of your new formulary.

Are there any drugs not eligible for Part D transition?

Drugs that fall under Medicare Part B coverage or some drugs that are excluded from Medicare Part D coverage are not eligible for Part D transition. Also not eligible are drugs that need prior authorization to determine if a drug is covered under Medicare Part B or Medicare Part D, or for safety reasons based on Food and Drug Administration (FDA) guidelines. (These drugs are covered with an approved prior authorization in place.)

Some transition supplies may not be processed because the FDA recommended dosage, or quantity limit, is less than what your provider has prescribed. Your pharmacist may reduce the quantity to the FDA limit and fill your request in order to give you time to talk to your provider about alternatives or to request a formulary exception.

What If my level of care changes?

A change in your level of care, such as admission to a long-term care facility, may result in a need for additional medication. However, requests for additional medication may be denied due to timeframe, i.e. trying to fill your prescription too soon after the last fill. If this happens, the pharmacy can call and request an override in order to fill your prescription.

Are emergency supplies of non-formulary drugs covered?

Blue Cross of Idaho does cover emergency supplies of non-formulary Part D drugs if you are outside the 90-day transition period and residing in a long-term care facility. You receive a 31-day supply, or the total amount of the medication, whichever is less. You can use this time to request a formulary exception.

How do I request a formulary exception?

Ask your provider for help and have them call the provider number on the back of your prescription drug card. We will make a decision about the request within 72 hours or less. If your provider feels your health is at risk, they can ask for an expedited exception and we will make a decision within 24 hours or less. If we deny your exception request, you have the right to appeal our decision.

How do I appeal a denied exception request?

Send a signed and dated letter, stating your request for appeal via mail or fax to the following:

Blue Cross of Idaho
Attn: Medicare Advantage Appeals
PO Box 8406
Boise, ID 83707
Fax: 1-208-331-8829

For an expedited appeal, call Customer Service at 1-888-494-2583, TTY users can call 1-800-377-1363. We are available from 8 a.m. to 8 p.m. seven days a week.

Y0010_MK 13121 Approved 12-31-2012
Last updated 11-14-2012