Our transition policy applies to Blue Shield Promise Cal MediConnect Plans. 

Blue Shield of California Promise Health Plan will provide its members a temporary supply of Part D medications at the point-of-sale for all planned transitions per the requirements set by Centers for Medicare & Medicaid Services (CMS). This policy is applicable to:

  • Newly eligible members transitioning from other coverage at the beginning of a contract year.
  • Transitioning individuals who switch from one plan to another after the beginning of a contract year
  • Current enrollees affected by negative formulary changes from one contract year to the next. Negative formulary changes include drugs removed from the formulary or formulary drugs with new prior authorization and step therapy restrictions.
  • Enrollees residing in long-term care (LTC) facilities. Blue Shield of California Promise Health Plan will work quickly and efficiently with all parties involved to provide the medication in a timely manner. Members will be provided prompt transitional notice and information on the exception or prior authorization process.

Transition policy for newly enrolled members

i. Newly enrolled members include but are not limited to:
  • new members enrolled into the plan following the annual coordinated election period;
  • members new to Medicare transitioning from other coverage;
  • members transitioning from another plan after the beginning of the contract year.
ii. The first effective date with the plan of all newly enrolled members will be provided to the Pharmacy Benefits Manager (PBM) as part of the eligibility file. This effective date will be the start date for the transition period, which will have a 90-day timeline. The end of the 90-day timeline may cross over contract years if the effective start date is after November 1 (i.e., the transition period will be extended across contract years should a beneficiary enroll with Blue Shield of California Promise Health Plan with an effective enrollment date of either November 1 or December 1 and need access to a transition supply).
  • During the member’s transition period, all edits associated with non-formulary drugs, meaning (1) Part D drugs that are not on the Plan’s formulary, (2) drugs previously approved for coverage under an exception once the exception expires, and (3) Part D drugs that are on the Plan’s formulary but require prior authorization or step therapy, or that have an approved quantity limit lower than the beneficiary’s current dose, under the Plan’s utilization management rules, will automatically be overridden by the claims adjudication system at the point-of-sale. Blue Shield of California Promise Health Plan will ensure that its coverage determination policy addresses procedures for medical review of non-formulary drug requests, and when appropriate, a process for switching new Part D plan enrollees to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination.
  • Non-Part D drugs and Part D exclusions will continue to be rejected at the point-of-sale.
  • Blue Shield of California Promise Health Plan will apply all transition processes to a brand-new prescription for a non- formulary drug if it cannot make the distinction between a brand-new prescription for a non-formulary drug and an ongoing prescription for a non-formulary drug at the point- of-sale.
  • The number of transition fills will be limited to the amount established by the member’s benefit plan. In the retail setting, the transition policy provides for a one-time temporary fill of a month’s supply of medication (unless the enrollee presents with a prescription written for less than a month’s supply in which case multiple fills will be allowed to provide up to a total of a month’s supply of medication) anytime during the first 90 days of a beneficiary’s enrollment in a plan, beginning on the enrollee’s effective date of coverage.
  • This temporary supply of Non-formulary or Formulary Drugs that have utilization edits, will 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.
iii. For any transition claims involving a safety issue (such as exceeding FDA maximum dosage, or inconsistent with product labeling), the system will reject the claim. The pharmacist will authorize the FDA-maximum dose and provide information about the exception process for additional dosage. As necessary, Blue Shield of California Promise Health Plan will provide refills for drugs in this category.

Transition policy for current members affected by negative formulary changes from one contract year to the next

Negative formulary changes include drugs removed from the formulary or formulary drugs with new utilization edits (prior authorization and step therapy restrictions).

i. For current enrollees whose drugs will be affected by negative formulary changes in the upcoming year, Blue Shield of California Promise Health Plan will effectuate a meaningful transition by providing a transition process at the start of the new contract year. The PBM’s claims adjudication system is able to accommodate this as follows: a) At the beginning of the calendar year (January 1st), the claims adjudication system will look back 180 days reviewing approved claims history of the member for the same prescription product. Upon finding a match the system will automatically provide the transition supply at the point-of-sale (in retail setting for a minimum of a thirty (30) day supply, unless the enrollee presents with a prescription written for less than thirty (30) days in which case the Part D sponsor must allow multiple fills to provide up to a total of thirty (30) days of medication). The transition timeframe of ninety (90) days will apply and the number of transition fills will be limited to the amount established by the member’s benefit plan.

ii. For any request involving a safety issue (such as exceeding FDA maximum dosage, or inconsistent with product labeling), the system will reject the claim. a) The pharmacist will authorize the FDA-maximum dose and provide information about the exception process for additional dosage. As necessary, Blue Shield of California Promise Health Plan will provide refills for drugs in this category.

Transition policy for members experiencing unplanned transitions involving level of care changes

Unplanned transitions involving level of care changes include but are not limited to:

  • Patients discharged from the hospital to a Long Term Care facility (LTC), or LTC to home
  • Patients discharged from hospital to home 
  • The end of a patient's LTC Part A stay

Upon notification of the change in level of care, either by the physician, pharmacy, discharge planner or member, the pharmacy technician will process this as a transition fill:

i. If the request is not a Part D exclusion or does not exceed the FDA safety maximum dose, a temporary transition supply (up to one month’s supply of medication unless the prescription is written for less) will be provided.
ii. If the request involves a safety issue (such as exceeding FDA maximum dosage, or inconsistent with product labeling), the pharmacist will authorize the FDA-maximum dose and provide information about the exception process for additional dosage. As necessary, Blue Shield of California Promise Health Plan will provide refills for drugs in this category.

Transition policy for members residing in Long Term Care facilities

Upon notification of the change in level of care, either by the physician, pharmacy, discharge planner or member, the pharmacy technician will process this as a transition fill:

i. Newly enrolled LTC members will have the same transition benefits as non- LTC members with a few exceptions. For members in the long-term care setting, the transition policy provides for a one time temporary fill of at least a month’s supply (unless the enrollee presents with a prescription for less) which will be dispensed incrementally as applicable under 42 CFR §423.154 and with multiple fills provided if needed during the first 90 days of a beneficiary’s enrollment in the plan, beginning on the enrollee’s effective date of coverage. Brand drugs are only allowed to be filled in increments of up to 14 days. After the transition period has expired, the transition policy provides for a 31-day emergency supply of non-formulary Part D drugs (unless the enrollee presents with a prescription written for less than 31 days) while an exception or prior authorization is requested. For members being admitted to or discharged from a LTC facility, early refill (dispensed too soon) edits are not used to limit appropriate and necessary access to their Part D benefit, and such members are allowed to access a refill upon admission or discharge.

ii. For any request involving a safety issue (such as exceeding FDA maximum dosage, or inconsistent with product labeling), the system will reject the claim. a) If the request is not a Part D exclusion or does not exceed the FDA safety maximum dose, a temporary transition supply (up to one month’s supply of medication unless the prescription is written for less) will be provided.

Transition extension

Arrangements will be made to continue to provide necessary drugs to enrollees via an extension of the transition period, on a case-by-case basis, to the extent that their exception request or appeal 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 decision on an exception request). On a case-by-case basis (upon consultation with Medical Director), point-of-sale overrides can also be entered by the Plan in order to provide continued coverage of the transition drug(s).