Through this document PacificSource Medicare is documenting how it will maintain an appropriate transition process consistent with 42 CFR 423.120(b)(3). PacificSource Medicare will make this transition policy available to enrollees via a link from the Medicare Prescription Drug Plan Finder to our web site (Medicare.PacificSource.com) and include in pre- and post-enrollment marketing materials as directed by CMS.
PacificSource Medicare, with the help of CVS Caremark (the plan designated Pharmacy Benefit Manager) will support the CMS required transition process for enrollees' prescribed Part D drugs that are non-formulary (not covered) or formulary drugs with Step Therapy, Quantity Limit, or Prior Authorization ("PA") requirements by offering an integrated solution at a retail, home delivery, home infusion, or ITU pharmacy. These transition policies apply to beneficiaries who are:
Within the first 90 days of a beneficiary's enrollment in the plan and beginning on the beneficiary's effective date of coverage, PacificSource Medicare will allow enrollees a one-time temporary fill (multiple fills for LTC) for at least a 30-day fill (31-days for LTC and PERS). However, if the prescription is for less than a 30-day supply (or 31-days for LTC and PERS) the member will be eligible for multiple fills up to at least a 30-day (31-days for PERS and 31 day's for LTC or as multiple 14 day fills if required by CMS guidance) supply for all Part D eligible medications that are non-formulary (not covered) or formulary, with Step Therapy, Quantity Limit, or PA requirements unless grandfathered by the Plan.
If after the temporary fill is provided, a transition is not made either through a switch to an appropriate formulary drug, or decision of an exception request, continuation of drug coverage may be managed through a PA override. CVS Caremark systems capabilities will provide eligible beneficiaries a temporary supply of non-formulary Part D drugs in order to accommodate the immediate needs of an enrollee, as well as to allow the plan and/or the enrollee sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or the completion of an exception request to maintain coverage of an existing drug based on medical necessity reasons. PacificSource Medicare's process for providing an extension of the transition period, an emergency fill for LTC members, or a level of care change is outlined later in this document.
There may be patient cost sharing for a temporary supply of drugs provided under this transition process. Cost-sharing for a temporary supply of drugs will never exceed the statutory maximum co-payment amounts for low-income subsidy (LIS) eligible enrollees. For non-LIS eligible enrollees, cost-sharing for a temporary supply of drugs will be based on approved cost-sharing tiers and consistent with cost-sharing that the plan would charge for non-formulary drugs approved under a coverage exception. The plan designated exceptions tier is used for non-formulary transition supply fills. Formulary transition supply will receive the same cost sharing that would apply for a formulary drug subject to utilization management edits provided during the transition that would apply once the utilization management criteria are met. This is done based on IT logic implemented by the PBM to assess the enrollee's status and apply the appropriate cost sharing.
The Transition Process requirements will be applicable to:
IT logic and rules will be implemented during the adjudication process to enable the temporary fill. These processes will only allow Medicare Part D eligible drugs to adjudicate. This will be determined based on a Part D eligible flag within the system. If the claim does not meet the transition fill criteria, the claim will reject appropriately and will not include messaging regarding the transition fill.
PacificSource Medicare makes available prior authorization or exception request forms upon request to both enrollees and prescribing physicians via a variety of mechanisms, including mail, fax, email, and on our website (Medicare.PacificSource.com).
For new enrollees, the system will work in the following manner:
For Current Enrollees moving across contract years the Transition process will work in the following manner:
For new members who become eligible for Transition at the end of the Plan Year
PacificSource Medicare, with the help of CVS Caremark, extends the member transition across contract years through a 180 day look back. During the first 90 days of eligibility in the plan, the member is processed as eligible for the new enrollee Transition process. This approach supports the transition requirement should a beneficiary enroll in a plan with an effective enrollment date of either November 1 or December 1 and need access to a transition supply.
PacificSource Medicare supports the CMS requirement to continue to provide necessary Part D drugs to enrollees via an extension of the transition period, on a case-by-case basis, to the extent that their exception requests or appeals have not been processed by the end of the minimum transition period and until such time as a transition has been made (either through a switch to an appropriate formulary drug or a favorable decision on an exception request). Such requests are handled by the PacificSource Medicare Pharmacy Services Helpdesk, which is trained to support this requirement.
Level of Care Change Transitions
When a beneficiary has a level of care change (e.g. admitted to LTC facility), they may need additional supplies of their medications. When this occurs, the pharmacy can call PacificSource Medicare to obtain an override for the situation or for early refill edits. Early refill edits will not be used to limit appropriate and necessary access to Part D benefits for enrollees being admitted or discharged from a Long Term Care facility. This is managed by the PacificSource Medicare Pharmacy Services Helpdesk who can issue overrides directly to the pharmacy.
Emergency Access to Non-formulary Drugs
PacificSource Medicare will cover an emergency supply of non-formulary (or formulary drugs with Step Therapy, Quantity Limit or PA requirements) Part D drugs for LTC facility patients when the enrollee is outside their 90 day transition period while an exception is being processed. In these instances, a 31 day supply or the total amount of the prescription, whichever is less, will be dispensed. This is managed by the PacificSource Medicare Pharmacy Services Helpdesk who can issue overrides directly to the pharmacy.
The PacificSource Medicare exceptions and appeals process takes into account special circumstances to ensure that beneficiaries have access to non-formulary (or formulary drugs with Step Therapy or PA requirements) medications. An example of this situation would include when beneficiaries are discharged from a hospital. The exceptions and appeals process is described below with a description of the P&T committee involvement in the process.
The PacificSource Medicare clinical override administration process enables Pharmacy Services Helpdesk personnel to review exceptions to the benefit design using established criteria. Criteria are approved by Pharmacy & Therapeutics (P&T) committee. Medical exceptions to the benefit design include products excluded from coverage by the pharmacy benefit (benefit exclusion) and non-formulary products. The P&T committee meets on a regular basis, but no less than quarterly and reviews procedures for coverage determination and exceptions, and, if appropriate, a process for switching new Enrollees to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination.
Medical Review Process - We use the following steps to review requests for medications that are non-formulary, require a prior authorization, or are subject to step therapy or quantity limits. If, at the end of this process, a member is rejected, they are advised on the appeal process and may work with their provider to determine the appropriate formulary alternative. This notification advises the member of the contact information and process for appealing a decision.