Drug Transition Policy

MDwise Medicare offers a transition process that aligns with the Centers for Medicare and Medicaid Services requirements for providing a temporary supply of a Part D drug if certain criteria are met.

New Members

To be eligible for a temporary supply, new members must be taking a Part D drug that is either:

  1. Not on the MDwise Medicare formulary, or
  2. Is subject to utilization management such as prior authorization, step therapy or quantity limits.

If you are a new member and your drug meets one of the above criteria, MDwise Medicare will cover a one-time, 30-day supply of a Part D covered drug during the first 90 days of your enrollment in our plan, beginning on the effective date of your coverage. If your doctor writes your prescription for less than a 30-day supply due to quantity limits, safety edits or drug utilization edits that are based on approved product labeling, MDwise Medicare will allow for multiple fills to provide up to a total of a 30-day supply of a covered medication.

Existing Members

For existing members whose drug will be affected by a negative formulary change in the upcoming year, MDwise Medicare will provide a transition at the start of a new contract year. If this applies to you, MDwise Medicare will cover a one-time, 30-day temporary supply during the first 90 days of the calendar year. If your doctor writes your prescription for less than a 30-day supply due to quantity limits, safety edits or drug utilization edits that are based on approved product labeling, MDwise Medicare will allow for multiple fills to provide up to a total of a 30-day supply of a covered medication.

For existing members who reside in a long-term care (LTC) facility whose drug will be affected by a negative formulary change in the upcoming year, MDwise Medicare will:

  • At the start of a new contract year, provide a transition that will cover a one-time, 31-day temporary supply during the first 90 days of the calendar year. If your doctor writes your prescription for less than a 31-day supply due to quantity limits, safety edits or drug utilization edits that are based on approved product labeling, MDwise Medicare will allow for multiple fills to provide up to a total of a 31-day supply of a covered medication.
  • After the transition period has expired, provide for a 31-day emergency supply of non-formulary Part D drugs (unless your prescription was written for less than 31 days) while an exception or prior authorization is requested.

After you get a transition supply

Once you receive a transition fill, our plan will send you a letter explaining that the supply you received is temporary and providing you with instructions for working with our plan and your doctor to meet utilization management requirements or find an appropriate equivalent drug that is on our formulary. The letter will also explain your right to request a formulary exception and the procedure for doing so.

For questions about the MDwise Medicare transition policy, please call 800-910-4691.

View 2024 Transition Policy