Medicare Part D Transition Process

Transition Policy applies to:

• Part D drugs that are not on the plan’s formulary
• Part D drugs that are on the plan’s formulary but require Prior Authorization under
  the plan’s utilization management rules.
• Enrollees within the first ninety days of enrollment into the plan
• You are an enrollee taking a greater quantity than the plan’s limit on the number of pills
  (quantity limit).

Initial Transition of Beneficiaries to Medicare Part D 2009

Sterling Retiree Rx will provide a 31-day transition supply for non-Formulary drugs and/or Formulary drugs requiring Prior Authorization. A 31-day transitional supply will be granted under certain conditions anytime during the first 90 days of the enrollee’s effective date of coverage. The standard guidelines for obtaining a Prior Authorization or a Coverage Determination will be adhered to. After your first 31-day supply, we will not grant another Transitional supply of the same medication, even if you have been a member of the plan less than 90 days. Once the transition supply is given you will receive a letter and a form to request coverage of such medication within 3 business days.

Our goal is to transition enrollees from the Non-Formulary drug to a therapeutic equivalent drug
that is included in the Formulary.

Sterling Retiree Rx Enrollees

Sterling Retiree Rx will provide a 31-day transition supply, when presented with a new prescription outside the 90-day transition period, while waiting for the approval of a Prior Authorization request or upon denial of a Prior Authorization request. Enrollees can initiate a request for Coverage Exception by contacting the Sterling Retiree Rx Customer Care Center and requesting a Coverage Exception Form, which they can give to their physician to complete and submit to the Plan. The prescribing physician or the member can contact Sterling Retiree Rx by phone, fax or mail. The Coverage Exception Form can also be downloaded from website.

Transition Policy — Other Circumstances

Hospital to Long Term Care Facilities

Sterling Retiree Rx beneficiaries who enter Long Term Care (LTC) facilities from hospitals will receive a 31-day transition supply (with multiple refills as necessary) of the non-Formulary medication(s). In the event the LTC facility requires a 90-day fill, the transition supply will accommodate the LTC facility. The early refill edit will not limit the enrollees’ access to the plan benefits upon entering the LTC facility.

Residents of Long Term Care Facilities

Sterling Retiree Rx will authorize a 31-day transition supply (with multiple refills as necessary), for enrollees. In the event the LTC facility requires a 90-day fill, the transition supply will accommodate the LTC facility. In addition, Sterling Retiree Rx will provide 31-day emergency supply for any enrollee, when presented with a new prescription outside the 90-day transition period when a Coverage Exception or Prior Authorization is being processed.

Hospital or Long Term Care to Home

Sterling Retiree Rx beneficiaries, who are discharged from a hospital or a skilled nursing facility to home, and need to revert back to the Sterling Retiree Rx plan Formulary will need to adhere to the plan’s Exceptions and Appeals processes. Transition supplies will be granted while the beneficiary waits for the exception process or a Prior Authorization. The early refill edit will not limit the enrollees’ access to the plan benefits upon discharge.

Retail & Long Term Care

Prescriptions submitted for less than a 31 days supply, will be the days supply granted in the transition override.

Pricing during a Transition Override

Co-payments/Coinsurance will be consistent with the tier in which the drug qualifies. If an enrollee qualifies for low-income subsidy (LIS), the applicable cost share amount will apply.

Non Verified Past History

If the distinction cannot be made between a brand-new prescription for a non-formulary drug and an ongoing prescription for a non-formulary drug, a 31-day “first fill” transition supply will apply.

Written Notice

Anytime a transition supply or transition override is granted, members will receive written notice within 3 business days explaining the transition override along with a Coverage Determination Form or a Prior Authorization Form.

Written Notice Includes:

• Explanation of the transition policy
• Sterling Retiree Rx Formulary, to identify possible formulary alternatives
• A Coverage Determination Form
• Explanation of the Coverage Determination process To determine if a prescription drug is included in the Sterling Retiree Rx Formulary, please call the Customer Care Center
  at 1-800-313-7667, Monday through Friday from 8:00 AM to 11:00 PM (EST) or visit www.sterlingretireescripts.com for formulary, transition and coverage determination policies.