Transition Supply Plan

The Windsor Pharmacy Department will manage and coordinate the Medicare Part D Transition Process through the Windsor pharmacy network. The Windsor transition process for new members will assure timely access to needed drugs while allowing for the flexibility necessary for Windsor to administer our pharmacy benefit design that promotes member choice and affordable access to medically necessary drugs. To address the needs of individuals who are stabilized on certain drug regimens when they join, Windsor has established an appropriate transition process for new members who are transitioning to Windsor from other prescription drug coverage — including other Part D plans — and whose current drug therapies may not be included in Windsor’s formulary.

The Windsor transition processes address situations in which members are stabilized on non-formulary drugs, formulary drugs that require prior authorization, step therapy or quantity limit under Windsor’s utilization management rules. Additionally, Windsor’s transition processes address cases in which a current or new member changes their setting of care, for example from a hospital to a home or institutional setting, to provide uninterrupted access to needed drugs.

Lastly, the Windsor transition process addresses the needs of new full-benefit dual members who may be auto-enrolled in the prescription drug plan, who, despite education and outreach efforts on the changing nature of their drug coverage under the Medicare benefit, may be unaware of the impact of the prescriptions drug plan’s formulary or utilization management practices on their existing drug regiments.

Windsor Policy Description

The transition process shall be applicable to non-formulary drugs, meaning both: (1) Part D drugs that are not on Windsor’s formulary and (2) Part D drugs that are on Windsor’s formulary but require prior authorization, step therapy or quantity limit under Windsor’s utilization management rules. Additionally, the transition process shall be applicable to: (1) new members into prescription drug plans on January 1 of each year following the annual coordinated election period; (2) newly eligible Medicare members from other coverage who enroll during the year, including dual eligible patients who may be auto-enrolled; (3) individuals who switch from one plan to another after January 1 of each year; (4) members residing in long-term care (LTC) facilities; and (5) auto-members.

Windsor’s Pharmacy and Therapeutics (P&T) committee will review and provide recommendations regarding the procedures for medical review of non-formulary and prior approval drug requests. P&T committee involvement will help ensure that transition decisions appropriately address situations involving members stabilized on drugs that are not on the Windsor’s formulary (or that are on the formulary but require prior authorization or step therapy under Windsor’s utilization management requirements) and which are known to have risks associated with any changes in the prescribed regimen.

Temporary Three-Time Fills: Non-Formulary (NF), Prior Approvals (PA), Step Therapy (ST), Quantity Limits (QL) For Retail, Home Infusion and Long Term Care (LTC) When a prescription for a drug is NF or requires a PA, ST or QL is presented at a participating Retail, LTC or Home Infusion pharmacy, Windsor will provide access to Part D drugs that are not normally covered. At point-of-sale or point-of-dispensing, the pharmacist shall enter the following override codes in the Prior Authorization field for the appropriate rejection. A message on the rejection will indicate the appropriate code to use in order for the claim to be resubmitted and paid.

Non-Formulary Drug—654321
Prior Approval—998877
Step Therapy—887766
QL—776655

These codes will accommodate the immediate needs of all members, as well as to allow Windsor and/or the member sufficient time to work out with the prescriber 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. Irrespective of transition, all of these edits are subject to exceptions and appeals. A pharmacist technical help desk is available 24 hours per day, 7 days per week at 1-800-658-0424 to assist providers with assistance if needed.

Cost Sharing

Windsor will charge cost-sharing for a temporary supply of drugs provided under its transition process. Cost-sharing for transition supplies for low-income subsidy (LIS) eligibles shall never exceed the statutory maximum copayment amounts. For non-LIS members, Windsor shall charge cost-sharing based on one of its approved drug cost-sharing tiers, and this cost sharing shall be consistent with cost-sharing that the plan would charge for non-formulary drugs approved under a coverage exception.

Transition Timeframes

1) RETAIL/HOME INFUSION

Windsor shall provide a transition period of three-month 30-day fill (unless the member presents with a prescription written for less than 30 days) when a member presents to a retail or home infusion pharmacy setting (or via home infusion, safety-net, or I/T/U pharmacies) and requests to fill a NF, PA, ST, or QL drug within the first 90 days of their coverage under Windsor. Since certain members may join Windsor at any time during the year, this requirement will apply beginning on a member’s first effective date of coverage, and not only to the first 90 days of the contract year.

2) LONG TERM CARE (LTC)

Windsor shall provide a transition period of three-month 31-day fill to members obtaining their drugs in a long-term care setting within the first 90-days of their coverage. Since certain members may join Windsor at any time during the year, this requirement will apply beginning on a member’s first effective date of coverage, and not only to the first 90 days of the contract year. The transition supply of NF, PA, ST, or QL drugs for a new member in a LTC facility shall be for at least 31 days (unless the prescription is written for less than 31 days). Windsor shall honor multiple fills of NF, PA, ST, and QL drugs as necessary during the entire length of the 90-day transition period using the override codes provided above.

Since, as a matter of general practice, LTC facility residents must receive their medications as ordered without delay, Windsor shall cover an emergency supply of NF Part D drugs for LTC facility residents as part of their transition process. During the first 90 days after a member’s enrollment, he or she will receive a transition supply via the process described above. However, to the extent that a member in a LTC setting is outside his or her 90-day transition period, Windsor shall still provide an emergency supply of non-formulary Part D drugs — including Part D drugs that are on a plan’s formulary but require PA, ST or QL under a plan’s utilization management rules — while an exception is being processed. The emergency supplies of non-formulary Part D drugs — including Part D drugs that are on Windsor’s formulary but require prior authorization or step therapy under Windsor’s utilization management rules — shall be for at least 31 days of medication, unless the prescription is written by a prescriber for less than 31 days.

The same process will apply to members with level of care changes and will apply to the following:

Members discharged from a hospital to a home
Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to the Windsor Part D formulary
Members who give up hospice status to revert to standard Medicare Part A and B benefits
Members who end a long-term care facility stay and return to the community
Members who are discharged from psychiatric hospitals with medication regimens that are highly individualized
Members who are auto-assigned

Transition Notices

A successful transition process is contingent upon informing members and their caretakers about their options for ensuring that member’s medical needs are safely accommodated within the Windsor Part D formulary. Windsor’s pharmacy claims processor shall provide a nightly report that captures transition fills. Windsor will send a written notice, via U.S. mail, to each member who receives a transition fill. This standard is consistent with our requirement that other member communications, including formulary change notices and explanations of benefits, be sent via U.S. mail. In addition, this notice shall be sent to each affected member within three business days of the transition fill.

The notice includes the following elements:

An explanation of the temporary nature of the transition supply an member has received;
Instructions for working with Windsor and the member’s prescriber to identify appropriate therapeutic alternatives that are on Windsor’s formulary;
An explanation of the member’s right to request a formulary exception;
A description of the procedures for requesting a formulary exception;
The reason for a transition fill
Point-of-sale notification of members consistent with the current NCPDP 5.1 standard
Alternative formulary drugs; and
How to obtain prior authorization or exception request forms a member will need to effectuate a transition. Prior authorization or exception request forms are available upon request to both members and prescribing physicians via a variety of mechanisms — including by mail, fax, email, and on plan websites.

Summary

The Windsor Pharmacy Department will manage and coordinate the Medicare Part D Transition Process through the Windsor pharmacy network. It is the responsibility of participating pharmacy providers to comply with transition policy and procedure as outlined above. The clinical pharmacy technicians, under the direct supervision of the pharmacy director shall ensure the coordination and management of the transition policy. Continuous educational efforts shall occur to educate providers regarding transition policies by targeting the top dispensing pharmacies.