If the pharmacy says your drug isn't covered under your new or changed plan, ask about a transition fill. Medicare.gov says that when your drug coverage begins, you may get a one-time, 30-day supply of a drug you've been taking that your plan doesn't cover or that needs prior authorization or step therapy. Use that month to work with your doctor on a covered drug or ask your plan for an exception.
Why does this happen in January?
New coverage and plan changes usually start January 1. A drug that was fine last year might now:
- Be off your plan's drug list (formulary).
- Need prior authorization.
- Need step therapy, meaning the plan wants you to try another drug first.
- Have a quantity limit.
The Annual Notice of Change your plan sent in the fall should have listed these changes. See your Annual Notice of Change.
What is a transition fill?
Medicare.gov describes it as a one-time, 30-day supply of a drug you've been taking that your plan either doesn't cover or requires prior authorization or step therapy for. It gives you time to sort things out without going without your medicine.
Medicare.gov also says to check with your plan for its specific rules, since details can vary.
What should I say at the pharmacy counter?
Ask the pharmacist to check before you leave.
What to say:
"This is a drug I've been taking for a while, and my coverage just changed. Can you check whether my plan will allow a transition fill? If not, can you tell me why the claim was rejected: is it not on the list, does it need prior authorization, or is there a quantity limit?"
Write down the reason. It tells you which next step to take.
Before you pay full price, ask the pharmacist whether running it again or calling the plan's pharmacy help line could fix it. Sometimes a claim is rejected for a simple reason, like the plan not having your new member information yet.
What if the transition fill went through?
Now you have about a month. Here's how to use it:
- Call your doctor's office. Tell them the plan won't keep covering the drug and why.
- Ask if a covered drug would work for you. Your plan's drug list shows covered options.
- If you need this drug, ask your doctor to request an exception or prior authorization from your plan. See Part D formulary exceptions.
What to say to your doctor's office:
"My Medicare drug plan, [plan name], gave me a one-time transition fill of [drug]. After this, it needs [prior authorization / an exception / step therapy]. Can the doctor either switch me to a covered drug or send the plan a request with a supporting statement?"
How do I ask my plan for a decision?
Asking your plan to cover a drug is called a "coverage determination." Medicare's appeals booklet says you, your representative, or your doctor can ask. You can call or write the plan, or use the "Model Coverage Determination Request" form.
Timeframes from Medicare's booklet:
- Standard request: a decision within 72 hours after the plan gets it. For an exception, it's 72 hours after the plan gets your doctor's supporting statement.
- Fast request: a decision within 24 hours, if waiting could seriously harm your health. Medicare's booklet says you can't get a fast decision if you've already paid for and gotten the drug.
- Request to be paid back: a decision within 14 calendar days.
If the plan says no, it must send a written decision, and you can appeal. See how to appeal a Medicare denial, step by step.
What if I already paid full price?
Keep the receipt. If your plan later approves coverage, you can ask to be paid back. Medicare's booklet says the plan decides payment requests within 14 calendar days.
What to say to your plan:
"I paid out of pocket for [drug] on [date] at [pharmacy] because the claim was rejected. My doctor has now [sent a supporting statement / gotten approval]. How do I ask to be paid back, and where do I send the receipt?"