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Part D Medicare Transition Problems Have Solutions!
1/09/06
The following is an update by the Disability Policy Collaboration
The January 1 transition of 6.4 million dual eligibles (including 500,000 individuals with developmental disabilities) from Medicaid prescription drug coverage to the new Medicare Part D coverage has been problematic from some, despite the extensive nationwide outreach efforts to educate beneficiaries, their families, providers and pharmacists.
Advocates should know that the Centers for Medicare and Medicaid Services (CMS) established protections to ensure that dual eligibles will not leave the pharmacy without their medications. CMS is working with the Part D prescription drug plans (PDPs) and pharmacists on implementation of these critical protections. Below are four examples of common problems and suggestions for resolving them to ensure that dual eligibles have access to their medications.
Problem #1
The pharmacist tells the beneficiary that their drugs are not on the formulary (list of approved drugs) of the Part D prescription drug plan in which the dual eligible was auto-enrolled or that the drug is subject to prior authorization by the PDP and cannot be dispensed without the PDP’s approval.
Solution
The Centers for Medicare & Medicaid Services (CMS) expects all PDPs to provide a “first fill” or 30-day supply of non-formulary drugs. This is known as the PDP’s “transition policy.” CMS sent a “reminder” letter to the PDPs, which can be found here. If questions arise about the PDP’s transition policy, the pharmacist should call the PDP’s technical assistance line or the CMS Pharmacy Help Line.
Note: During this 30-day transition period, dual eligibles should seek assistance (e.g. by calling 1-800-MEDICARE (1-800-633-4227) in choosing a PDP with a drug formulary that includes all of their medications or seek assistance from their medical providers in the event that a plan covering all of their medications cannot be found.
Problem #2
A pharmacist charges the beneficiary for the Part D deductible and/or a high co-pay.
Solution
Dual eligibles are not required to pay deductibles under Part D. If a dual eligible’s income is under 100 percent of the federal poverty level ($9,570 annually for an individual), he or she is required to pay $1 for each preferred (usually generic) medication or $3 for each non-preferred (usually brand name) medication as described by the PDP. If an individual’s annual income is above 100 percent of the federal poverty level, then the co-pay is $2 for the preferred medication and $5 for the non-preferred. A dual eligible residing in ICFs/MR or a nursing facility will not be required to pay co-pays. Pharmacists can query the CMS computer system or call the CMS dedicated pharmacy eligibility line to determine Part D plan enrollment.
Problem #3
Some dual eligibles have not received their PDP identification (ID) card because they switched plans in mid-to-late December. Dual eligibles take their new PDP’s “acknowledgment letter” to the pharmacy or go to their pharmacy without an “acknowledgment letter,” but the pharmacist will not fill the prescription without the ID card.
Solution
Pharmacists can query the CMS computer system or call the CMS dedicated pharmacy eligibility line to determine Part D plan enrollment.
Problem #4
A dual eligible comes to the pharmacy with only a Medicaid card and appears Medicare eligible but the pharmacist cannot determine if the beneficiary has been auto-enrolled in any plan.
Solution
If the pharmacist believes the individual is a dual eligible and cannot get confirmation from the CMS computer software program, the point of service contractor (Anthem) can be billed.
The Disability Policy Collaboration (DPC) is working closely with CMS to ensure that all dual eligibles obtain the prescription drugs they need. This critical information should be disseminated to chapter/affiliate networks, civic organizations, religious groups, and others who can reach people outside the immediate DPC network.
A new section has been added to the DPC’s Medicare Part D Web site with more information about transition policy. You can also find an FAQ on this subject here.
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