By: Wanda Lund
How can
you quickly identify potential rejections for prior authorizations, non-formulary
fills, quantity supply, and step therapy requirements?
The Medicare Part D Transition Policy allows some patients
access to prescription drugs within 30 days of their enrollment in a Medicare
Part D plan.
The 30-day transition requirement applies to both long-term
care and outpatient settings. This limits the time pharmacies and physicians
have to identify impacted prescriptions and discuss therapy options with their
patients. Pharmacies need to be efficient and proactive when
managing these claims.
A Transition Supply is a temporary 30-day prescription supply or refill of a non-formulary drug
for:
- Patients who remain with the same Medicare Part D
prescription plan into the next year, but find that their existing medications
are no longer covered due to formulary changes.
- Patients who joined a new Medicare Part D
prescription plan during Open Enrollment and discover that their medications
are not covered under their new plan.
- Patients who find that their medication is still
covered by their Medicare Part D plan, but the plan now includes usage
restrictions, such as Quantity Limits, Prior Authorization, or Step Therapy.
The Medicare Part D 30-day Transition Supply Policy allows
enrollees to have immediate access to prescription drugs, within 90 days of plan
enrollment. It applies to both
non-formulary drugs and drugs with utilization requirements (i.e., prior
authorizations, quantity limits, step therapy, etc.). The policy does not apply to new
prescriptions, drugs that have been removed from a plan’s formulary due to U.S.
Food and Drug Administration drug recalls or Medicare Part D excluded
drugs.
During the 30-day transition supply window, patients are
expected to work with their physicians to discuss alternative medications
covered under their plan, or to request an exception. Pharmacists can proactively
address transition refills and formulary changes by discussing treatment
options with patients and contacting their physicians on their behalf.
Click here to See How Formulary Status Affects Claim Responses and Reimbursement
Pharmacies
should identify and react to prior authorization expiration dates, quantity
limit warnings, and step therapy requirements weekly. Contact the prescribing
physician and/or plan as necessary; keep patients informed of any changes to
their medication therapy.
Your dispense system may provide payer messages on a
claim-by-claim basis. However, sifting
through hundreds or even thousands of claims to search for specific messages is
a very tedious and time-consuming task.
Net-Rx™ is a provider of pharmacy
reimbursement solutions specifically for pharmacies. Save time and increase
efficiency using our Metric-Rx® Payer Messaging Report. This report lists all claims with payer
messages regarding transition supply, formulary warnings, prior authorization
notices, and other similarly impacted claims.
With the list of payer messages in hand, you can reduce
claim rejections by managing transition supply changes, addressing formulary
restrictions, and processing prior authorization renewals before the transition
period is over.
Accelerate your workflow and improve efficiency
Read more articles that cover topics such as Average Wholesale Price and pharmacy success through COVID-19.
References: https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-policy-changes-and-updates-medicare-advantage-and-prescription-drug-benefit-program
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