Part D Emergency Supplies in Long-Term Care: Which Policy Applies?

The short answer: one of three federal mechanisms, picked by resident status

An urgent medication order for a long-term care resident can fall under more than one federal rule. The first question is whether Medicare Part D is the payer at all. During a covered Medicare Part A skilled-nursing stay, the Part A payment includes the facility's pharmacy charges, and the resident returns to the Part D formulary when that stay ends. If the resident has elected hospice, 42 CFR section 418.202(f) covers, as hospice services, drugs used primarily for the relief of pain and symptom control related to the terminal illness. A drug outside that hospice coverage can still be a Part D claim. Only a drug that is Part D's responsibility moves into the Part D access rules below.

Inside Part D, three instruments do different jobs. They are easy to collapse into one "emergency supply," and the day counts attached to them come from different documents.

• Transition supply during the first 90 days of coverage under the plan. Current 42 CFR section 423.120(b)(3) requires a temporary supply of at least an approved month's supply, with multiple fills allowed to reach that month, when the drug is non-formulary or is on the formulary but requires prior authorization or step therapy. The same section applies that 90-day window to long-term care pharmacies. Medicare Prescription Drug Benefit Manual, Chapter 6, section 30.4.4.2, Revision 18 (January 15, 2016), still tells sponsors that a new long-term care enrollee's transition supply must be for at least 91 days and may be up to at least 98 days, and it cites 42 CFR section 423.120(b)(3)(iii)(B). That paragraph is not in the current regulation text.

• One-time emergency supply after the transition window. Manual Chapter 6, section 30.4.6, requires an emergency supply of non-formulary Part D drugs of at least 31 days of medication, unless the prescriber wrote for fewer days, while an exception or prior-authorization request is processed. The manual limits this to one 31-day emergency fill of a particular drug per long-term care stay. That day count is manual guidance. Section 423.120 does not state it.

• Coverage-determination clock. A standard drug-benefit determination is due as expeditiously as the enrollee's health requires and no later than 72 hours under 42 CFR section 423.568. An expedited determination is due on the same health standard and no later than 24 hours under 42 CFR section 423.572, when 42 CFR section 423.570 requires the plan to expedite. A missed deadline is itself an adverse coverage determination, and the plan must forward the request to the Independent Review Entity.

A 72-hour supply is a Medicaid pharmacy obligation under section 1927(d)(5) of the Social Security Act. It is a different program from the Part D 72-hour decision clock. A 96-hour supply does not appear in the Part D statute, in section 423.120, or in Manual Chapter 6.

flowchart TD
    A["Urgent order for a long-term care resident"] --> B{"Is this a covered Part A skilled-nursing stay?"}
    B -- "Yes" --> C["Part A payment includes the facility pharmacy charges\nBill Part D only for a drug outside that payment"]
    B -- "No" --> D{"Hospice election, and is the drug related?"}
    D -- "Yes" --> E["Hospice is responsible for the related drug"]
    D -- "No" --> F{"Non-formulary, or blocked by prior authorization or step therapy?"}
    F -- "No" --> G["Ordinary Part D fill\n14-day cap applies only to brand-name solid oral doses"]
    F -- "Yes" --> H{"Inside the first 90 days of coverage under this plan?"}
    H -- "Yes" --> I["Transition fill\nCurrent 423.120: approved month's supply\n2016 Manual 30.4.4.2: at least 91 and up to at least 98 days\nUse the plan's transition policy"]
    H -- "No" --> J["Manual 30.4.6 emergency supply\nAt least 31 days, once per drug per stay\nWhile an exception or prior authorization is processed"]
    I --> K["File the exception or prior authorization in parallel"]
    J --> K
    K --> L{"Prescriber indicates the 72-hour clock may seriously jeopardize life, health, or function?"}
    L -- "Yes" --> M["Expedited determination\n42 CFR 423.570 and 423.572\nNo later than 24 hours"]
    L -- "No" --> N["Standard determination\n42 CFR 423.568\nNo later than 72 hours"]

Before any fill: confirm the drug is Part D's responsibility

Long-term care pharmacies see the payer class change with clinical status, hospital history, and benefit days. A transition override sent before that check bills the wrong program.

Manual Chapter 6, section 30.4.7, describes beneficiaries who end a skilled-nursing facility Medicare Part A stay, "where payments include all pharmacy charges," and who then need to revert to the Part D plan formulary. While the covered Part A stay is open, drugs included in that payment are Part A's responsibility. Part D becomes the drug benefit when the stay is custodial, when Part A skilled coverage has ended, or when the particular drug is outside the Part A payment. The manual also says an early-refill edit cannot be used to block an appropriate refill when an enrollee is admitted to or discharged from a long-term care facility.

Hospice is a separate gate. Under 42 CFR section 418.202(f), covered hospice services include drugs used primarily for the relief of pain and symptom control related to the individual's terminal illness. A drug outside that hospice coverage can still be billed to Part D. The plan's hospice-coordination process is what sorts a particular claim. How that relatedness file is built is covered in the companion article on Medicare Part D hospice drug coverage.

For the hospice boundary, see Medicare Part D hospice drug coverage and billing coordination.

A product excluded from the Part D definition is outside every transition and emergency path. Section 1860D-2(e)(2) of the Social Security Act takes out of Part D the drugs for which payment is available under Part A or Part B as prescribed, and categories such as over-the-counter drugs, drugs used for anorexia, weight loss, or weight gain, fertility drugs, and cosmetic drugs. Examples of drugs that are often Part B rather than Part D include certain oral antiemetics within 48 hours of chemotherapy and immunosuppressive drugs after a Medicare-covered transplant. An excluded product is not converted into a Part D drug by a transition fill or an emergency supply.

Mechanism 1 — the LTC transition supply (first 90 days)

The transition process is the continuity rule for a drug the enrollee is already using when coverage under a new plan starts, or when a negative formulary change would interrupt it. Current 42 CFR section 423.120(b)(3) requires an appropriate transition process for Part D drugs that are not on the plan's formulary, including formulary drugs that require prior authorization or step therapy. The process must reach four groups: new enrollees following the annual coordinated election period; newly eligible Medicare enrollees from other coverage; individuals who switch from one plan to another after the start of the contract year; and current enrollees remaining in the plan who are affected by formulary changes. It does not apply to immediate changes permitted under section 423.120(e)(2).

The regulation then requires access to a temporary supply within the first 90 days of coverage under a new plan. That 90-day timeframe applies to retail, home infusion, long-term care, and mail-order pharmacies. During that period, the sponsor must provide a one-time temporary supply of at least an approved month's supply, unless the prescriber wrote for less, and must allow multiple fills to provide up to a total of an approved month's supply. Written notice is due to the enrollee within three business days after adjudication of the temporary fill. For a long-term care resident who receives multiple supplies in increments of 14 days or less, consistent with 42 CFR section 423.154, the written notice is due within three business days after adjudication of the first temporary fill.

Manual Chapter 6, section 30.4.1, Revision 18, lists five situations in which a transition process is necessary. The fifth item is enrollees residing in long-term care facilities, and the manual's cross-reference for that item is section 30.4.6, the emergency-supply section. Level-of-care changes are not one of the five. They are addressed separately in section 30.4.7.

1. New enrollees into prescription drug plans following the annual coordinated election period.

2. Newly eligible Medicare beneficiaries from other coverage.

3. Enrollees who switch from one plan to another after the start of the contract year.

4. Current enrollees affected by negative formulary changes across contract years.

5. Enrollees residing in long-term care facilities. The manual points this group to section 30.4.6.

Section 30.4.4.2 is the manual's long-term care day count, and it is older than the current regulation. It says the transition supply of non-formulary Part D drugs for a new enrollee in a long-term care facility must be for at least 91 days, and may be up to at least 98 days, consistent with the applicable dispensing increment, unless the prescriber wrote for less. Sponsors must allow multiple fills if needed. The manual cites 42 CFR section 423.120(b)(3)(iii)(B) for that instruction. The current codified paragraph (b)(3)(iii) is a single approved-month's-supply rule. It has no subparagraph (B) and no 91-day or 98-day figure. CMS still hosts Revision 18, issued January 15, 2016, as the Chapter 6 file. Treat 91 and 98 days as that manual's instruction, dated and sub-regulatory, and read the plan's filed transition policy before treating either number as the fill the plan will pay.

The 98-day figure is the manual's way of fitting a 14-day brand dispensing increment around a supply of at least 91 days. Seven 14-day increments equal 98 days. The manual says the supply may be up to at least 98 days so the increment can be honored. It does not create a statutory maximum of 98 days, and the current regulation does not require seven consecutive 14-day transition fills.

Section 30.4.4.1 still describes the retail transition fill as at least 30 days, citing former paragraph (b)(3)(iii)(A), which is also absent from the current regulation. Medicare & You 2027 tells beneficiaries that, within the first 90 days after drug coverage starts, they may get a one-time transition fill: a 30-day supply of a drug they have been taking that the plan does not normally cover or that usually requires prior authorization or step therapy, and that they should contact the plan. The handbook states that 30-day beneficiary rule. It does not restate the 2016 manual's 91-to-98-day long-term care instruction.

Section 30.4.3 addresses a new prescription versus ongoing therapy. CMS says a minimum 108-day look-back is typically needed to document ongoing therapy. If the sponsor cannot make the distinction at the point of sale, the sponsor must provide the transition fill. A brand-new prescription for a non-formulary drug is treated the same as ongoing therapy when the point-of-sale system cannot tell them apart. For protected-class drugs subject to prior authorization or step therapy on new starts only, if the sponsor allows an initial fill because it cannot determine that the enrollee is not already taking the drug, the manual says the sponsor shall treat the enrollee as currently taking the drug.

How a Part D transition fill differs from a manufacturer bridge program, including timing and true-out-of-pocket treatment, is a separate question for community and specialty access teams. That comparison is in Part D transition fills versus manufacturer bridge programs.

Section 30.4.7 covers unplanned level-of-care changes: hospital discharge into a facility, the end of a Part A skilled stay, the end of hospice status, discharge from the facility back to the community, and similar moves. For those changes, the manual says beneficiaries and providers use the exceptions and appeals process, and that coverage determinations must be made as expeditiously as the enrollee's health condition requires. CMS encourages sponsors to build transition supplies for current enrollees into their transition plans for these changes. Encouragement in section 30.4.7 is not the same legal sentence as the required temporary supply in section 423.120(b)(3).

The manual also lets a sponsor send the required transition notice to the long-term care pharmacy, instead of directly to the resident, if the transition policy delegates that delivery, the sponsor can show the pharmacy accepted the delegation, an electronic notice reaches the pharmacy within three business days of adjudication, and the pharmacy can show the resident or representative received it within the three-day period. That option has to be in place before the contract year. Otherwise the sponsor mails the notice to the beneficiary.

Mechanism 2 — the one-time 31-day emergency fill (current LTC enrollees)

The first-90-days rule ends. A resident who has been in the same plan for six months can still have an immediate need for a non-formulary drug on a weekend. Manual Chapter 6, section 30.4.6, is the text that answers that case. It says long-term care residents must receive medications as ordered without delay, so sponsors must cover emergency supplies of non-formulary Part D drugs after the transition period. If the resident is outside the 90-day transition period, the sponsor must still provide an emergency supply while an exception or prior-authorization request is being processed. The supply must be for at least 31 days of medication, regardless of dispensing increments, unless the prescriber wrote for less than 31 days. The manual says a sponsor is not expected to provide more than a one-time 31-day emergency fill of a particular drug per long-term care stay. Multiple fills of 14 days or less can be used for brand-name drugs to meet that 31-day minimum.

The undated CMS questions-and-answers memorandum, Emergency Supply of Medications for Long Term Care Residents, is the earlier statement of the same policy. It clarifies the March 16, 2005 long-term care guidance. It does not set a day count. It says plans must cover an emergency supply of non-formulary Part D drugs for long-term care residents as part of the transition process, while an exception is adjudicated, because residents receive medications as ordered without delay and because withholding that supply would discourage enrollment by long-term care residents. CMS describes that result as discriminatory. The 31-day minimum and the once-per-stay limit come from the 2016 manual, not from this memorandum and not from section 423.120.

Short-cycle dispensing is a separate rule, and it applies to a narrower set of products than "every long-term care fill." 42 CFR section 423.154, applicable January 1, 2013, requires pharmacies serving long-term care facilities to dispense solid oral doses of brand-name drugs in no greater than 14-day increments. The section excludes solid oral doses of antibiotics, and solid oral doses dispensed in their original container as indicated in FDA prescribing information or customarily dispensed in original packaging to support compliance, with oral contraceptives given as the example. CMS waives the 14-day requirement, except the uniform-dispensing and payment-methodology conditions, for pharmacies serving intermediate care facilities for individuals with intellectual disabilities and institutions for mental diseases, and for I/T/U pharmacies. A generic solid oral dose is outside the 14-day brand rule. An inhaler, an ophthalmic drop, or an oral liquid is not a solid oral dose of a brand-name drug, so the 14-day increment does not attach to it under this section.

When the emergency supply is a brand-name solid oral dose, the pharmacy meets the manual's 31-day minimum in more than one dispensing event, often a 14-day increment followed by another short increment, unless the coverage decision arrives first. A generic solid oral product can be dispensed for the prescribed emergency quantity in one fill, because section 423.154 limits the 14-day increment to brand-name solid oral doses.

Submission clarification codes do not create the emergency supply. CMS Part D event data, documented in the CMS Blue Button submission-clarification-code value set, record how a long-term care dispensing event was coded. In that value set, code 07 is an emergency supply of a non-formulary drug, or of a formulary drug that typically requires step therapy or prior authorization, when the physician has determined the medication is medically necessary. Code 18 is a long-term care admission or readmission that required a new dispensing. Code 21 means the 14-day-or-less dispensing rule is not applicable because of a CMS exclusion or because the manufacturer's packaging cannot be broken for special dispensing. Code 34 is a 14-day long-term care supply. Code 16 is replacement of an emergency box or automated dispensing machine. A claim that pairs code 18 with code 21 is an admission indicator plus a statement that the short-cycle rule does not apply. It is not an emergency-supply override. The plan's payer sheet, not a universal pair of codes, tells the pharmacy which value that sponsor accepts.

Section 30.4.8 limits which edits a sponsor may apply during a transition fill. Permitted edits include edits that sort Part A or Part B coverage from Part D, edits that block non-Part D drugs, and edits that promote safe use, including a beneficiary-level opioid claim edit, a quantity limit based on an FDA maximum recommended daily dose, and an early-refill edit. If a safety edit shortens the dispensed quantity below the written amount, the manual says the sponsor must still provide refills to meet the transition-supply requirement. Opioid point-of-sale edits may apply during transition, within the dosage the case-management process has already found medically necessary. A safety edit is not a reason to invent a 72-hour or 96-hour Part D entitlement.

Mechanism 3 — the coverage-determination clocks (24 and 72 hours)

A transition fill and an emergency supply are temporary. They do not add the drug to the formulary. The coverage determination runs at the same time.

Under 42 CFR section 423.568(b), when a party requests a drug benefit, the plan must notify the enrollee, and the prescribing physician or other prescriber as appropriate, as expeditiously as the enrollee's health condition requires, but no later than 72 hours after receipt of the request. For an exception, the 72-hour period runs from receipt of the prescriber's supporting statement. If that statement has not arrived by the end of 14 calendar days after the exception request, the plan must decide no later than 72 hours after those 14 calendar days end. A completely favorable decision may be given orally first, with written notice sent within three calendar days of the oral notification. A denial may also be given orally first, with the written denial mailed within three calendar days.

Under 42 CFR section 423.570(c)(3), if the enrollee requests expedition, the plan expedites when it determines that the standard timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function. If the prescribing physician or other prescriber makes or supports the request and indicates that the standard timeframe may seriously jeopardize life, health, or the ability to regain maximum function, the plan provides an expedited determination. A denial of expedition moves the request onto the 72-hour standard clock in section 423.568(b), and the plan gives prompt oral notice of that denial.

Under 42 CFR section 423.572(a), once expedition is granted, the plan makes the determination and notifies the enrollee, and the prescriber as appropriate, as expeditiously as the enrollee's health requires, but no later than 24 hours after receiving the request. For an exception, the 24 hours run from receipt of the prescriber's supporting statement, with the same 14-calendar-day outer rule if the statement does not arrive. If the plan first notifies the enrollee orally, it mails written confirmation within three calendar days of the oral notification.

Section 423.568(h) and section 423.572(d) treat a missed deadline the same way. Failure to notify the enrollee in the required timeframe constitutes an adverse coverage determination, and the plan must forward the enrollee's request to the Independent Review Entity within 24 hours of the expiration of the adjudication timeframe. The forwarding deadline is measured from the end of the 24-hour or 72-hour decision period, not from the moment the pharmacy first transmitted the claim. The file should show when the request was received and, for an exception, when the prescriber's supporting statement was received.

Where the 72-hour supply and the 96-hour phrase come from

Facility staff often ask for a "72-hour emergency supply" or a "96-hour weekend dose." In Medicare Part D, 72 hours is a decision deadline, and 96 hours is not a supply right.

The 72-hour supply belongs to Medicaid. Section 1927(d)(5) of the Social Security Act requires a state that uses prior authorization for covered outpatient drugs to respond within 24 hours of the request and to dispense at least a 72-hour supply in an emergency. The MACPAC August 2024 issue brief on prior authorization in Medicaid restates that statute. The brief does not prescribe an NCPDP submission clarification code for the Medicaid override. State pharmacy manuals do that, and a state Medicaid code is a Medicaid billing instruction. A resident who has both Medicare and Medicaid can meet both rules on the same order: section 1927(d)(5) for the Medicaid supply, and sections 423.568 and 423.572 for the Part D decision clock.

A 96-hour supply is not stated in the Part D statute, in 42 CFR section 423.120, in sections 423.568 or 423.572, or in Manual Chapter 6. Staff use the phrase for weekend and holiday delivery gaps and for state facility or Medicaid billing conventions. A Part D plan has no federal "96-hour override" that corresponds to that phrase. The Part D amounts in play are the approved month's supply in the current transition regulation, the 2016 manual's 91-to-98-day long-term care transition instruction, and the manual's one-time 31-day emergency supply.

An emergency medication kit or stat box stored in the facility is a different object again. State board of pharmacy rules and the pharmacy-service contract govern what may sit in the kit and how a dose removed from it is replaced. Removing a dose from the kit does not, by itself, adjudicate a Part D transition fill or a Part D emergency supply. Code 16 in the CMS long-term care submission-clarification value set identifies replacement of an emergency box or automated dispensing machine. It is a dispensing description, not a coverage approval.

Plan-level conditions: read the transition policy and Evidence of Coverage

Sponsors file a transition policy that says how they will carry out these rules. Member pages often describe a 31-day long-term care supply during the first 90 days. That sentence matches an approved month's supply more closely than it matches the 2016 manual's 91-to-98-day instruction. It is a plan document. It does not amend the regulation, and the 2016 manual does not amend the plan's Evidence of Coverage. For any one resident, the pharmacy reads the policy attached to that plan and contract year.

Blue Cross NC's page, reviewed October 2, 2026, also says certain drugs may not be eligible for a transition supply at the pharmacy and first require a review to determine whether the Part D plan can cover them. That is a plan-level pre-fill review. It is consistent with the manual's point that some safety and Part A or Part B edits still apply during transition. It is not a federal rule that protected-class drugs are ineligible for a transition fill. Other sponsors' 2026 policies have to be read in their own PDFs. A table that attributes a specific override code, a 98-day ceiling, or a protected-class exclusion to a sponsor whose document does not say that is not usable for a claim.

Cost sharing on a temporary supply provided under the transition process is set by 42 CFR section 423.120(b)(3)(vi) and restated in Manual Chapter 6, section 30.4.9. For a low-income-subsidy enrollee, the sponsor must not charge higher cost sharing for the transition supply than the statutory maximum copayment amounts. For a non-LIS enrollee, the sponsor charges the same cost sharing for a non-formulary transition drug that would apply to a non-formulary drug approved through a formulary exception under section 423.578(b), and the same cost sharing for a formulary drug subject to a utilization-management edit that would apply once those criteria are met. The regulation does not describe this amount as the lowest tier that contains a non-preferred alternative.

The dollar maxima change every year. The CMS calendar year 2026 low-income subsidy cost-sharing memorandum sets the 2026 copayment, below the out-of-pocket threshold, at $0 for full-benefit dual eligible beneficiaries who are institutionalized or receiving home- and community-based services; $1.60 generic and $4.90 brand for full-benefit dual eligible beneficiaries with income at or below 100 percent of the federal poverty level; and $5.10 generic and $12.65 brand for full-benefit dual eligible beneficiaries with income between 100 and 150 percent of the poverty level and for the other full-subsidy categories in that table. The memorandum states that the 2026 out-of-pocket threshold is $2,100, and that there is no cost sharing for covered Part D drugs above that threshold. Medicare & You 2027 says that a person with Medicaid who lives in certain institutions, such as a nursing home, or who receives certain home- and community-based services, pays nothing for covered drugs, and that in 2027 drug costs for people who qualify will generally be no more than $5.80 for a generic and $14.40 for a brand-name drug at a network pharmacy. Those 2027 sentences are not the 2026 table. A 2026 fill uses the 2026 memorandum.

The emergency supply in manual section 30.4.6 is described as part of the transition process, which is why plans often apply transition cost sharing to it. The codified cost-sharing sentence itself is in the transition paragraph. Confirm the amount on the paid claim response rather than assuming the transition copay attaches to every emergency increment. For how the Inflation Reduction Act redesign and the Medicare Prescription Payment Plan sit next to these copays, see the Medicare Part D redesign and Medicare Prescription Payment Plan opt-in failures.

What changes in 2027: emergency fills as Manufacturer Discount Program drugs

The Inflation Reduction Act replaced the Coverage Gap Discount Program with the Manufacturer Discount Program under section 1860D-14C of the Social Security Act, beginning January 1, 2025. Manufacturers that have an agreement provide discounts on applicable drugs in the initial coverage phase and in the catastrophic phase. The standard discount is 10 percent in the initial coverage phase and 20 percent in the catastrophic phase, subject to the statutory phase-in for specified manufacturers and specified small manufacturers. The 2026 out-of-pocket threshold is $2,100, from the CMS 2026 low-income subsidy memorandum. The older $2,000 figure was the 2025 starting point of the redesigned benefit, not the 2026 threshold.

The Contract Year 2027 Medicare Advantage and Part D final rule (Federal Register document 2026-06600, published April 6, 2026) is effective June 1, 2026, and applicable to coverage beginning January 1, 2027. In that rule, CMS codifies that, for the Manufacturer Discount Program, an applicable drug includes a Part D drug provided to an applicable beneficiary as a transition fill under section 423.120(b)(3) or as an emergency supply required for a long-term care resident. The preamble describes the clarification as codifying the approach CMS already used under the Coverage Gap Discount Program. The definition is about discount accounting for coverage beginning in 2027. It does not change how a 2026 claim is discounted, and it does not change the day count of a transition fill or an emergency supply.

For a manufacturer, a plan, or a long-term care pharmacy reconciling 2027 discounts, the operational point is narrow: a transition fill and a long-term care emergency supply can be applicable drugs when the other applicable-drug conditions are met. The rule does not say that every weekend fill qualifies, and it does not say that the pharmacy may skip the payer check, the plan's transition policy, or the coverage-determination request.

Worked example: one Friday-night fill, documented

The following walkthrough is illustrative. It uses a hypothetical custodial admission on Friday, October 2, 2026, at 7:45 p.m. It does not describe a real plan, a paid claim, a copay, or a promise of coverage. The resident was admitted from home to a custodial bed, with no open Part A skilled-nursing payment and no hospice election. The resident enrolled in an MA-PD plan 42 days earlier. The order is for a brand-name solid oral antiarrhythmic, and the claim rejects because the product is not on the formulary.

1. Confirm the payer. The admission record shows a custodial stay, not a covered Part A skilled-nursing stay, and no hospice election. The product is a Part D drug. The claim stays in Part D.

2. Choose the instrument from enrollment timing. Forty-two days is inside the first 90 days of coverage under this plan, so the transition process in section 423.120(b)(3) is the regulatory path: at least an approved month's supply, with multiple fills up to that month. The 2016 manual's section 30.4.4.2 would describe a new long-term care enrollee's supply as at least 91 days and up to at least 98 days. The pharmacy reads this plan's transition policy before assuming either amount. If enrollment had been outside 90 days, manual section 30.4.6 would be the emergency-supply text: at least 31 days, once for this drug during this stay, while the exception is processed.

3. Apply short-cycle only to the products it covers. This order is a brand-name solid oral dose, so section 423.154 limits the increment to no more than 14 days. The first dispensing event is a 14-day increment, not a 90-day bottle. If the same order were a generic solid oral tablet, the 14-day brand cap would not apply.

4. Resubmit with the code this plan's payer sheet requires. CMS event coding would describe a 14-day long-term care supply as code 34, an admission or readmission as code 18, and an emergency supply of a non-formulary drug as code 07. Code 21 means the 14-day rule does not apply, so it is the wrong code for a brand solid oral dose that is being dispensed in a 14-day increment. None of these codes approves coverage. The claim response, not the code label, shows whether the plan paid a transition fill.

5. Start the coverage determination the same evening. At 8:15 p.m. the consultant pharmacist sends an exception request with the prescriber's supporting statement. If the prescriber indicates that applying the 72-hour timeframe may seriously jeopardize life, health, or the ability to regain maximum function, section 423.570 requires an expedited determination, and section 423.572 requires a decision no later than 24 hours after the plan receives that statement. The temporary fill does not decide the exception.

6. Track the notice from the first temporary fill. Section 423.120(b)(3)(iv) requires written notice within three business days after adjudication of that first fill when later increments are 14 days or less. The pharmacy log records the adjudication time so a missing notice is visible. The medication can be delivered for the evening pass only if the plan's response or the facility's own emergency-kit rules actually put a dose in hand. This example does not assume that result.

A compliance file for this kind of event is a record of decisions, not a stack of codes. The items below are the documents that show which rule was applied.

Sources

Dates below are the dates on the documents. Manual Chapter 6 is Revision 18, issued January 15, 2016, and it is still the Chapter 6 file CMS hosts. Section 30.4.7 inside that file keeps its own Revision 10 stamp, issued February 19, 2010. Regulation citations were checked against the current electronic Code of Federal Regulations text mirrored by the Legal Information Institute on October 2, 2026.

• Centers for Medicare & Medicaid Services. Medicare Prescription Drug Benefit Manual, Chapter 6 — Part D Drugs and Formulary Requirements. Revision 18 (January 15, 2016). Sections 30.4 through 30.4.10, including 30.4.1, 30.4.3, 30.4.4.1, 30.4.4.2, 30.4.6, 30.4.7, 30.4.8, and 30.4.9.

• Centers for Medicare & Medicaid Services. Emergency Supply of Medications for Long Term Care Residents. Questions-and-answers memorandum clarifying the March 16, 2005 long-term care guidance. No day count.

• 42 CFR section 423.120. Access to covered Part D drugs. Current transition process at paragraph (b)(3), including the approved month's supply, the three-business-day notice, and transition cost sharing at (b)(3)(vi).

• 42 CFR section 423.154. Appropriate dispensing of prescription drugs in long-term care facilities under PDPs and MA-PD plans. Brand-name solid oral doses in no greater than 14-day increments, with the stated exclusions and waivers. Applicability date January 1, 2013.

• 42 CFR section 418.202. Covered hospice services. Paragraph (f) covers drugs used primarily for the relief of pain and symptom control related to the terminal illness.

• 42 CFR section 423.568. Standard timeframe and notice requirements for coverage determinations. Seventy-two-hour drug-benefit timeframe, oral notice with written follow-up within three calendar days, and forwarding to the Independent Review Entity under paragraph (h).

• 42 CFR section 423.570. Expediting certain coverage determinations. When an enrollee request or a prescriber's indication requires an expedited determination.

• 42 CFR section 423.572. Timeframes and notice requirements for expedited coverage determinations. Twenty-four-hour timeframe and forwarding to the Independent Review Entity under paragraph (d).

• Centers for Medicare & Medicaid Services. Medicare Program; Contract Year 2027 Policy and Technical Changes. Final rule, Federal Register document 2026-06600 (April 6, 2026). Effective June 1, 2026, and applicable to coverage beginning January 1, 2027. Applicable-drug definition for transition fills and long-term care emergency supplies under the Manufacturer Discount Program.

• Blue Cross and Blue Shield of North Carolina. Medicare Part D transition policy. Member page reviewed October 2, 2026. Thirty-one-day long-term care transition supply during the first 90 days, and a possible emergency 31-day supply after that window.

• Centers for Medicare & Medicaid Services. Medicare & You 2027. CMS Publication No. 10050. One-time 30-day transition fill within the first 90 days, and 2027 Extra Help cost-sharing sentences.

• Centers for Medicare & Medicaid Services. Calendar Year 2026 Resource and Cost-Sharing Limits for Low-Income Subsidy. Table 2, 2026 maximum LIS beneficiary cost sharing, and the $2,100 out-of-pocket threshold.

• Centers for Medicare & Medicaid Services, Blue Button. Part D event submission clarification code values. Long-term care dispensing descriptions, including codes 07, 16, 18, 21, and 34.

• Medicaid and CHIP Payment and Access Commission. Prior Authorization in Medicaid. Issue brief (August 2024). Section 1927(d)(5) 24-hour response and 72-hour emergency supply.