Identifying Payer Messaging to Comply with Transition Supply Requirements Efficiently

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. 

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 with the Metric-Rx® Payer Messaging report. 

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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