What Is Transition?
A transition refill, also known as a transition fill, is typically a one-time, one-month supply of a drug that you’re taking. Transition refills let you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions (such as prior authorization or step therapy). You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage.
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each drug that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 31-day supply) for the applicable drug(s).
New and Renewing Members
Description
Transition Fill Supply
Not in long-term care
- 30-day supply within first 90 days in the plan
- Multiple fills up to a cumulative applicable month’s supply are allowed to accommodate fills for amounts less than prescribe.d
In long-term care
- 31-day supply within first 90 days in the plan
- Oral brand solids are limited to a 14-day supply with exceptions as required by CMS guidance.
- Multiple fills for a cumulative applicable month’s supply are allowed to accommodate fills for amounts less than prescribed or the first 90 days.
Non-Long-term Care Resident Level of Care Change
Description
Transition Fill Supply
Member released from long-term care facility within past 30 days
- 30-day supply
- Multiple fills up to a cumulative applicable month’s supply are allowed to accommodate fills for amounts less than prescribed.
The transition supply allows you time to talk to your doctor or other prescriber about pursuing other options available to you within our formulary. Your plan cannot continue to pay for these medications under the transition policy, even if you have been a member for less than 90 days following your one-month transition supply.
If you receive a transition supply, you will receive a letter from your plan notifying you that you have received a temporary supply of your prescription drug. Please refer to your Evidence of Coverage for more information on the CareFirst BlueCross BlueShield Advantage DualPrime transition process.
What scenarios could exist to prevent me from receiving a transition fill?
- Refill Too Soon (RTS): If it's too soon to refill your medication based on your previous fill, you will not receive transition. You may be able to receive one once this time period has expired.
- DUR Safety Checks: If there's a safety issue with how the medication is prescribed, the claim will be rejected and not allow a transition fill.
- Part A or B Only Drugs: These medications pay pursuant to a different benefit. Only Part D drugs will qualify for this type of fill.
- Part A or B vs. Part D (A or B vs. D): These medications may pay pursuant to a different benefit. Until it can be determined how they should pay, there can't be a transition fill.
- Excluded Drugs: If a drug isn't considered a Part D drug (OTC, weight loss, fertility, etc.) it will not be eligible for a transition fill.