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CMS Information on the Transition Period
Each Medicare Part D plan must have a transition process for those Medicare Beneficiaries who move between plans or move places where there existing medications are not covered by their current plan (or their are utilization restrictions on their medications such as Quantity Limits, Step Therapy, or Prior Authorization. Medicare provides:
:: What if I am taking a drug that is not covered by my plan, and I have not switched to an alternate drug by March 31, 2006?
:: What can I do at the pharmacy counter if I have not switched to an alternative drug by March 31, 2006, and can not fill the prescription for the drug I am taking now?
What if I am taking a drug that is not covered by my plan, and I have not switched to an alternate drug by March 31, 2006?
Call your plan to make sure you understand the transition process and your rights.
If your plan does not cover the drug you are taking now, it must cover an alternative drug that can work for you.
If your physician believes that you need the specific drug you are taking now, then the plan must have a timely way for you to ask to continue with that drug.
If the plan still does not allow you to continue with that drug, Medicare provides an independent review of your request. It is important to use this process if you want to continue your drug.
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What can I do at the pharmacy counter if I have not switched to an alternative drug by March 31, 2006, and can not fill the prescription for the drug I am taking now?
Ask the pharmacist if there is a generic alternative. In most states your pharmacist can fill your prescription with the generic drug. In some states, the pharmacist must check with your doctor first.
Ask your pharmacist why the drug is not covered.
Ask your pharmacist if he or she can suggest an alternative drug that your plan covers.
Call your doctor and ask about the alternative drug.
If your doctor does not think the alternative drug will work for you, call your plan to ask for an exception.
If it is urgent, ask the plan for an expedited review, which means they must make a decision in 24 hours.
Ask your plan if they will cover a temporary supply of your drug until they make a decision.
If you pay for a drug that the plan does not cover, and then your exception or appeal is approved, the plan is required to reimburse you up to the amount the plan would have paid if it covered the drug.
If you have any other questions, call 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1877-486-2048.
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Last updated on: 07/05/2009
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Life Insurance plays an important role in your families financial stability.
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