Keith LaFountaine
If you’ve never heard of “transition benefits” you aren’t alone. However, they are vitally important, especially to Medicare Part D beneficiaries who enroll in new plans. The transition period from one plan to another can be a nerve-wracking process and experience, and most members want to ensure one thing: that they’ll still be able to fill their prescriptions.
At Capital Rx, our next-generation enterprise health platform, JUDI®, consolidates all sorts of real-time pharmacy benefit management (PBM) workflows and processes, including data exchanges. With its efficiency and speed, we can notify members about their transition benefits, easing their concerns and meeting Centers for Medicare and Medicaid Services (CMS) requirements.
But we’re getting ahead of ourselves. What are transition benefits, why are they important, and how does JUDI help members in this respect?
We spoke with Samantha Custer (Director, Customer Experience) and Jake Mulkey (Manager, Product) to answer these questions and learn more.
What are transition benefits?
“In Medicare Part D, new enrollees are entitled to ‘transition benefits’ that lift certain drug restrictions – e.g. prior authorization (PA) requirements – for a limited time,” Samantha explained. “This aids members’ smoother entry into a new plan.”
Per CMS, these courtesy transitions must be followed up with written notification to the member and their prescriber, such that a prior authorization request can be initiated and reviewed in time for their next prescription fill. Letters must be postmarked within three days of the transition fill. This doesn’t leave much time to notify the member.
Failing to send these letters in a timely fashion not only disadvantages the member, who has less time to seek PA approval or discuss viable alternatives with their prescriber, but it also could put the plan at risk during a CMS audit.
How does modern PBM software make a difference?
We talk a lot about how unique JUDI is within the pharmacy benefit administration (PBA) industry. The platform’s modular design, for example, delivers a more unified experience for everyone involved, including allowing plan sponsors to choose the tools and services that work for them.
Some of JUDI’s capabilities, and their benefits, are intuitive. For example, since our Prior Authorization Tool (PAT) is built within JUDI, and since JUDI is a centralized platform, this tool allows for the review of PAs while leveraging other data, including eligibility, plan benefits, or formulary or claim adjudication data, to name a few examples. In this way, JUDI’s modules work together, efficiently enabling end-to-end servicing of client needs.
JUDI also supports real-time transactions – a claim will populate in JUDI within milliseconds when a member arrives at the pharmacy to pick up their prescription. This speed is unparalleled in healthcare. In comparison, medical claims take far longer to flow through the system.
Once we know a drug has been filled, the Capital Rx team can immediately perform outreach or intervention.
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How does JUDI’s modern design enable faster results and reliable compliance?
Capital Rx leverages a powerful combination of JUDI modules, our Member Communications team’s expertise, and integration with our print vendor to aid compliance with CMS.
Medicare plan sponsors can use the Plan Management module in JUDI to denote who is entitled to Medicare Part D transition benefits – and within what parameters. JUDI references this benefit configuration during the adjudication process, and transition fill claims are saved and annotated in our database in a special way that makes them easy to identify.
A report configured in JUDI’s Data Exchange module runs every morning to grab all relevant transition fills that were made the day before and transforms this data into something that can populate a letter template.
Jake further explained, “The breadth of data and connectivity options that our data reports product has access to made the setup of transition letters and integration with the necessary print vendor a breeze. With transition fills being saved and easily identifiable in JUDI’s database, the filtering and inclusion of claims that require lettering is as simple as a few clicks within the data report filters. Since our data reports module actively provides a history of executions, retrieving previous transition letter data is easy and can be done as needed to meet internal plan sponsor and audit needs.”
JUDI modules can also “inherit” from each other. Because of that, they don’t require manual tweaks to stay aligned and internally consistent. For example, should a plan sponsor make a change to the Medicare Part D benefit and widen their definition of who is a new enrollee, this change can be made once in the Plan Management module. After that, every downstream piece of the puzzle falls in place. Claims will adjudicate naturally against the more generous benefit configuration and flow all the way through to the Data Exchange module and out to our printing vendor without any additional intervention. This reduces the touchpoints necessary to make a change and minimizes opportunities for error.
In addition to this, JUDI de-couples transition benefits and transition letters. While some may speak about them in the same breath, the timelines involved with them – real-time claim processing versus a three-day window to send a letter – show there’s no reason to conflate the two. By de-coupling them, JUDI’s processes within the Plan Management module and claim adjudication itself aren’t burdened. We can update transition letter templates and data structures without putting upstream processes at risk.
The benefits of leveraging modern technology like JUDI are clear. There are processes in place that help so, and nobody has to worry about a member not being able to get their medication at the point of sale. And that’s just scratching the surface.
Learn More About JUDI’s Capabilities
Transition benefits are a legislative mandate. There is no opting out, and the risk of doing something incorrectly in this process is too high. So why not make it easier?
Leveraging JUDI, plan sponsors can implement a process that is streamlined, simple, and accurate. They will also have the answers for almost any question someone could come asking at their fingertips.
Click here to learn more about JUDI’s capabilities!