FAQs from NCPA Medicare Rx Forums

  1. Q: Do R.Ph.s Need to Waive Copays for Dual Eligibles?
  2. A: Many states today require copayments for Medicaid prescription drugs, but pharmacists are often obligated to waive the copayment for patients who say they cannot afford to pay.  While not necessarily the intent of state Medicaid policy, in some states it has become commonplace to waive copays on a routine basis.

    The Medicare Modernization Act changed this practice for “dual eligibles.”  Dual eligibles are current Medicare-eligible beneficiaries who are receiving Medicaid prescription drug benefits. These patients will lose their Medicaid prescription drug coverage on December 31, 2005 and be rolled over to Part D starting January 1, 2006. Dual eligibles cannot expect that pharmacists will waive their copay because of financial hardship.  However, “pharmacies are permitted to waive or reduce cost-sharing amounts provided they do so in an unadvertised, non-routine manner” if the patient demonstrates financial need or fails to pay the required copay.  It is important to note that pharmacies cannot advertise in any way that they waive copays.

    With as many as six million Medicare-eligible Medicaid patients being converted to Medicare Part D this fall, pharmacists must be prepared next year for patients unaccustomed to copayments being subjected to a small copayment fee structure.

    back to top

  3. Q: How will Social Security determine which plans to auto-enroll patients into?
  4. A: In most areas, the Social Security Administration (SSA) has already sent applications to limited income beneficiaries to see if they qualify for extra help with the prescription drug costs. It is not an application for coverage under a prescription drug plan. Patients will have to enroll directly with an approved Medicare prescription drug provider for coverage. If patients do not enroll directly with a prescription drug plan by May 2006, they will be auto-enrolled into a qualifying prescription drug plan.

    Social Security will not being auto-enrolling patients into a Medicare prescription drug plan.  The Centers for Medicare and Medicaid Services (CMS), the agency that runs Medicare, will be facilitating this auto-enrollment. When CMS auto-enrolls patients, they will do so in a “random basis,” consistent with the Medicare Modernization Act (MMA). CMS intends to randomly assign these patients among all prescription drug plans that offer at least one plan with a premium at or below the low income premium subsidy amount.

    It is important to remember that your Medicare eligible Medicaid patients (dual eligibles) will be auto-enrolled into a prescription drug plan in Fall 2005.  These patients do not need to complete the SSA application to qualify – your state will forward their eligibility information to Medicare.  All other limited income beneficiaries will need to complete the SSA application.

    back to top

  5. Q: Will there be a closed formulary? If so, who will determine what’s on the formulary and how often will it be reviewed and updated?
  6. A: Medicare prescription drug plans have the ability to establish their own formularies, so a closed formulary is a definite option for a plan. However, these formularies will be reviewed by CMS before the plan is approved. Prescription drug plans are required to include at least two drugs within each therapeutic category and class of covered Part D drugs within their formulary (unless there is only one drug in a particular therapeutic class or category, in which case the inclusion of only one drug in that category would be required). Also, there are six categories of diseases for which CMS said that plans must have all or substantially all of the drugs in the antidepressant, antipsychotic, anticancer, immunosuppressant and HIV/aids categories included in the formulary. 

    Prescription drug plans are required to use a Pharmacy and Therapeutic (P&T) committee to develop and review their formularies. The P&T committee will recommend any formulary changes to the prescription drug plan. These changes are not permitted between the beginning of the initial enrollment period and 60-days following the beginning of the contract year. After that point, specific drug changes can be submitted to CMS on a monthly basis. If there is a change of a formulary drug to a higher co-pay tier level during the year, the plan is required to notify patients, prescribers and pharmacists 60 days in advance.

    back to top

  7. Q: Some plans are sending contracts with very low reimbursement rates and zero dispensing fees. Does Medicare have any say as far as the payment offered by these providers?
  8. A: The MMA did not establish minimum or maximum reimbursement rates and dispensing fees. Additionally, the MMA specifically indicates that Medicare cannot intervene in negotiations between pharmacies and Part D plans. CMS has said, “the extent to which Part D plans reimburse pharmacies for their entire dispensing costs (or even in excess of their dispensing costs) will depend on the outcome of those negotiations."

    back to top

  9. Q: I understand that catastrophic coverage begins after $3,600 true out-of-pocket costs. Is the 3,600 annually or a lifetime?
  10. A: Annually. So, in 2006, catastrophic coverage will begin when a beneficiary reaches the threshold of $3,600 in true out-of-pocket costs for the year.  However, this threshold will likely increase each year.

    back to top

  11. Q: Do current Medicare-Approved Drug Discount Card holders need to re-apply for Medicare Part D or will they be auto-enrolled by their current plan?
  12. A: Current Medicare beneficiaries that are receiving an interim Medicare-Approved Drug Discount Card will need to apply for Medicare Part D this Fall. They will not be auto-enrolled by their current discount card program.  Some drug discount card sponsors will not be participating in Medicare Part D. However, those programs that are continuing to Part D will likely be reaching out to their current enrollees when marketing can begin in October.

    back to top

FAQ's
See answers to commonly asked Medicare questions:
-Pharmacist FAQs
FEATURED CE
Medicare Part D - Changes in 2007 That Will Affect Your Pharmacy
2006 brought massive changes to community pharmacy... Read more>>
Commercial Support Provided by Community Care Rx
MEDICARE RX BYTES:
Medicare Rx Bytes:
Beneficiaries Can File for Formulary Exceptions
Now that the initial transition phase has ended for Medicare Part D beneficiaries, most patients ........ Read more>>
DME RESOURCE CENTER
Medicare Part B DME Resource Center Now Available... Read more>>