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Tips for Managing Transition Fills & Prior Authorizations to Save Pharmacies Time and Money

By: Wanda Lund, Product Lead, Net-Rx

Managing transition fill prescriptions and prior authorizations causes extra work for the pharmacy, can increase the pharmacy’s transaction fees, and cause medication delays for the patient. However, pharmacies can benefit from proactively managing transition fills by working through prior authorizations and medication changes during the transition fill period. As we explain in this article, a proactive effort can save the pharmacy money on claims, reduce labor, and improve patient care.  

First, let’s explore why there are transition fills in the first place and how to identify them.

A Medicare Part D Transition Supply is a temporary 30-day prescription supply or refill of a non-formulary drug 1 for: 

  • Patients who remain with the same Medicare Part D prescription plan into the next plan year but find their existing medications are no longer covered due to formulary changes.
  • Patients who joined a new Medicare Part D prescription drug plan during the open enrollment period and discovered their current medications are not covered under their new plan.
  • Patients who find their Medicare Part D prescription drug plan still covers their medication, but the plan now includes coverage restrictions, such as quantity limits, dosage form limits, prior authorization, or step therapy requirements.

The Medicare Part D Transition Supply Policy provides patients with temporary coverage for prescription drugs they are currently taking. The transition policy is available to patients within 90 days of their enrollment in a new Medicare Part D plan or when their existing plan applies coverage restrictions or changes their drug formulary. 2  

The Transition Supply Policy does not apply to new prescriptions, drugs removed from a plan’s formulary due to U.S. Food and Drug Administration (FDA) drug recalls, or drugs excluded from Medicare Part D coverage.  

During the 30-day transition supply window, patients are expected to work with their healthcare providers to discuss alternative medications covered under their plan or to request an exception. Pharmacists can proactively address transition fills and formulary changes by discussing treatment options with patients and contacting their physicians on their behalf. This proactive work improves patient care, loyalty, and trust. It can also reduce claim rejections at the pharmacy, and the labor that is required to address them, as well as the associated transaction fees.

See How Formulary Status Affects Claim Responses and Reimbursement

Identifying Transition Fills

During the filling/billing process, payers often send warning messages in the payer response field, although these can be easily missed and are difficult to find after the fact. If the pharmacist or billing tech does not receive or notice the warning message sent from the payer during the billing process, they often won’t know to navigate to the payer response field to view the messaging.  

Unfortunately, the most common way pharmacy staff is made aware of the need to review a medication for a patient is after the transition fill window has expired and they receive a rejected claim. This leads to a disrupted workflow, additional fees and labor at the pharmacy, and delays in the delivery of patients’ medication while the care team resolves the situation.

Best practice tips to help manage Transition Fills:  

  • Look for warning messages from the payer, when filling or billing, by checking the claim’s payer response field and/or payer messaging field(s) within your dispense system
  • If your dispense system provides payer messaging after filling and billing has been completed, sift through your internal reporting to search for specific messages relating to transition supplies. Here is a sample of payer messaging related to transition supplies, prior authorizations, formulary, and quantity limits:
Transition Prior Authorization Formulary
  • Proactively identify and react to prior authorization expiration dates, quantity limit warnings, and step therapy requirements weekly, if not several times per week. Contact the prescribing physician to:
    • Inform them of potential medication change requirements by the plan, based on transition day supplies remaining
    • Initiate new prior authorization requests to the payer, before the current prior authorization expires
    • Make medication recommendations based on non-formulary alerts or formulary changes by the plan
    • Address quantity limits and step therapy requirements
  • To avoid delays and deliver a high level of patient care, keep patients informed of any upcoming changes to their medication therapy, whenever possible
  • Move the process of managing medication changes, addressing formulary restrictions, and processing prior authorization renewals to before the transition period expires

Fortunately, automated reporting is available to easily identify recent claims falling into the transition fill or prior authorization expiration bucket.

Net-Rx™ is a provider of reimbursement solutions for pharmacies. With Script-IQ ®, the Net-Rx pre-edit solution, pharmacies can identify and respond proactively to transition fill claims before the next fill is due with the daily Transition Fill report.   

This report helps:

  • Improve patient care by reducing medication delivery delays caused by transition fill rejections
  • Proactively address medication change requirements and prior authorization requests before the next fill is due
  • Avoid workflow disruptions and reduce switch fee costs by eliminating transition fill rejections

Transition fills can be burdensome for both pharmacies and patients. But with a proactive effort in applying best practices and leveraging automated tools, pharmacies can accelerate their workflow, improve efficiency, and enhance patient care.

Contact Net-Rx  to learn more about solutions that are designed to save your pharmacy time, labor, and money while improving patient care, including help in managing transition fills.

Read more articles that cover topics such as Average Wholesale Price and Optimizing Prescription Reimbursement

References: 

1https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-policy-changes-and-updates-medicare-advantage-and-prescription-drug-benefit-program

2https://www.cms.gov/newsroom/fact-sheets/transition-fact-sheet

Author:

Wanda Lund LinkedIn icon
Product Lead
Joined Net-Rx in 2009
 With over 20 years of pharmacy experience, Wanda’s extensive industry knowledge includes retail and long-term care pharmacy pricing, contracting, billing, reimbursement, analytics, and structuring technology platforms. As Product Lead, her skills play an essential role in her daily responsibilities to enhance and grow the Net-Rx portfolio of services and solutions. Wanda is passionate about helping pharmacies maximize their business growth, allowing the pharmacy to focus on patient care. She supports various positions from dedicated analysts, developers, product owners, and operations managers to ensure customer satisfaction and build trusting relationships with our customers, partners, and associates. Wanda lives in Central Washington and enjoys the region’s snow in the winter and heat in the summer. She is an avid animal lover, and enjoys watching football, camping, and spending time with family. 

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