US · guidance
CMS Pub. 100-18, ch. 6, App. E
Appendix E: Sample Transition Supply Scenarios and Eligibility
A Part D sponsor must provide for an appropriate transition process for certain enrollees who
are prescribed Part D drugs that are non-formulary in order to promote continuity of care and
avoid interruptions in drug therapy while a 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 can be effectuated. See Sections 30.4 – 30.4.11 for additional
guidance.
Coverage Year 1 Coverage Year 2 Transition Eligible?
Sponsor A
Plan ABC (on formulary)
Sponsor A
Plan ABC (on formulary)
No
No change in formulary
Sponsor A
Plan ABC (non-formulary and/or new
UM criteria)
Yes
Negative change; potential
interruption of coverage
Sponsor A
Plan EFG (on formulary)
No
No change in formulary
Sponsor A
Plan EFG (non-formulary and/or UM
criteria)
Yes
Non-formulary change; potential
interruption of coverage
Sponsor B
Plan JKL (on formulary)
No
No interruption of coverage
Sponsor B
Plan JKL (non-formulary and/or UM
criteria)
Yes
Non-formulary change; potential
interruption of coverage
Sponsor A
Plan DEF (non-formulary)
[filled under exception]
Any Sponsor
Any Plan (on formulary)
No
No interruption of coverage
Sponsor A
Plan DEF (non-formulary)
Yes
Plans may approve an exception
or transition to a formulary item
prior to the new contract year
Sponsor A
Plan DEF (on formulary, with UM
criteria)
Yes
Plans may approve an exception
or transition to a formulary item
prior to the new contract year
Sponsor B
Plan MNO (non-formulary and/or UM
criteria)
Yes
Potential interruption of coverage
History
(Rev. 18, Issued: 01-15-16, Effective: 01-15-16; Implementation: 01-15-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-09-17
- Edition
- iom-2026-09-17
- Content hash
d5d430852c368d11cf223be4dd308881ac367816f8d17fae2f5fcd16435120e1
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