Monday, February 27, 2006

Instructions to Texas Pharmacies re Medicare Part D

The Texas Health and Human Services Commission posted instructions for Texas pharmacies regarding Medicare Part D and how to handle issues with the transition from Medicaid to Medicare for prescription drug coverage on its web site a few weeks ago. Today's email carries the following reminder:

As you know, Texas is providing Medicaid prescription drug coverage for low-income Texans who are inappropriately denied medications under the new Medicare drug plans. While this coverage is available now, it is temporary and will not be available indefinitely. It’s important to prepare for the eventual transition back to the Medicare prescription drug program. [emphasis added]
That's an important reminder to consumers and case managers as well. The message continues with information about various places to get help with problems in the transition:

Don’t know what plan the beneficiary is enrolled in…

  • Pharmacists can call Medicare’s dedicated pharmacy assistance line at 1-866-835-7595. Pharmacists can get information on a beneficiary’s enrollment and on how to contact the plan.

If the plan does not recognize a low-income beneficiary as being eligible for reduced cost sharing…

  • The pharmacist must contact the prescription drug plan (PDP) to request approval for low-income cost sharing. Each PDP should have an expedited process for low-income, cost-sharing approvals.
  • If pharmacist cannot obtain approval for reduced cost-sharing from the PDP, and the situation is urgent, or other steps have not worked, contact the Medicare pharmacy assistance line at 1-866-835-7595.

What to do if the prescribed drug is not covered on your plan’s formulary…

  • If this is a refill of a prescription previously paid for by Medicaid, the plan should automatically fill the first time it is submitted. The pharmacist must contact the PDP for approval through their expedited process.
  • If the PDP does not approve the dispensing of the drug, the beneficiary may request an exception from the plan. If this is necessary, report these problems to Centers for Medicare and Medicaid Services (CMS) regional office at 1-214-767-6401.

Beneficiaries who need assistance in selecting a plan can contact 1-800-MEDICARE (1-800-633-4227) or a local Area Agency on Aging at 1-800-252-9240.

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