A Guide For Pharmacy Staff

                            CONSUMER CENTER FOR HEALTH EDUCATION AND ADVOCACY

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HELPING PEOPLE WITH MEDICARE AND MEDI-CAL RECEIVE THEIR PRESCRIPTION DRUGS

What Changed?

Beginning January 1, 2006, Medi‑Cal will no longer pay for most of the prescription drugs that people with both Medicare and Medi-Cal (also known as “Dual Eligibles” or “Medi-Medis”) were receiving.  Most of their drug coverage must now come from a Medicare Prescription Drug Plan (PDP).

What Issues are Medi-Medis Facing at Your Pharmacy?

Issue #1 – Medi-Medis come to the pharmacy and do not have their Medicare Part D prescription drug cards.

1.  Verify Medicare Part A/B eligibility and/or Part D enrollment and bill based on the

     following information

     ► Ask to see the Medicare card.

     ► Submit an E1 query to the TrOOP facilitator.  For E1 Query Questions, call 1-800-388-2316

        OR

     Use an offline method to check for Medicare Part A/B eligibility:

     ►  Request to see the Medicare card

     ► Call 1-800-MEDICARE (available 24/7)

     ► Call the dedicated Medicare pharmacy line (1-866-835-7595) available 24/7

             (NOTE: this line also gives Part D enrollment and plan information)

     ► Request to see a Medicare Summary Notice (MSN)

     ► If the E1 query returns Part D enrollment information, bill the appropriate plan

       OR

If the E1 query shows that the person is not enrolled in a Part D plan, the pharmacy can help the Medi-Medis get enrolled thru a Point of Service (POS) facilitated enrollment into a plan called Wellpoint.  Medi-Medis can get up to a 14-day fill immediately.  To do this:

     ►  Enter the claim into the Point of Sale (POS) facilitated enrollment system, including available

           beneficiary data, such as name, ID number (Medicare ID number, Medi-Cal ID number or SSN),

           date of birth, address, and phone number

     ►  Submit the claim to the unique BIN/PCN account indicated on the POS contractor’s payer sheet

     ►  Claim submitted to Payer: Anthem Prescription, LLC

     ►  Group Name: Medicare Part D

     ►  BIN: 610575

     ►  PCN: CMSDUAL01

     ►  In compliance with the paid claim response, provide the prescription drug to the beneficiary and collect a    

           co‑pay of $1 for generic or a preferred multi-source brand, $3 for any other brand

     ►  The POS contractor processes the claim as paid (network pharmacies) or as a captured response

           (out‑of‑network pharmacy)

     ►  If the pharmacy is out‑of‑network, special instructions are sent to the pharmacy to establish the

           mechanism for payment

     ► The POS contractor sends a daily file to the enrollment contractor with submitted beneficiary data

     ► The enrollment contractor uses this information to validate dual eligibility and returns a validation of

           eligibility or ineligibility to the POS contractor

     ►  If the individual is dually eligible and not enrolled in a Part D plan, the POS contractor enrolls him/her

           in a POS contractor plan

     ► All facilitated enrollees have the option to choose another plan

     ► The phone number for the Wellpoint Claims Processing Help Desk is 1-800-662-0210

2.  Check Medicaid (Medi-Cal) eligibility

            ►  Ask to see the Medi-Cal ID card; or

            ►  Check the recent history of Medicaid billing in pharmacy patient profile; or

            ►  Read a copy of the current Medi-Cal award letter

Issue #2 – Medi-Medis are having problems with paying deductibles or high co-pays

What you can do:

     ►  Call the beneficiaries’ prescription drug plan to obtain the reasons for charging those prices

     ►  Call the I-800-MEDICARE (1-800-633-4227)

Medi-Medis automatically receive the low-income subsidy, which is a government program that assists them with paying for deductibles, some monthly premiums, and most of their co-payments.  Because of the low-income subsidy, Medi-Medis should only be paying $1-2 for generic drugs and $3-5 for name brand drugs.   If they are being told that they have to pay for these costs, they should call 1-800-MEDICARE (1-800-633-4227) to resolve the issue.  After dialing the number, they should press zero (0) several times immediately in order to speak directly with a representative.   They should ask to speak with the Medicare Benefits Specialist Department. 

Centers for Medicare and Medicaid Services (CMS) has instructed plans to train their member services staff to assist pharmacists with overriding default benefit packages in the event that an enrollee presents at the pharmacy with evidence of dual eligibility or a Social Security Administration (SSA) eligibility determination of the low-income subsidy (“extra help”).

Issue #3 – Medi-Medis are having problem accessing the medications from their Medicare Part D plans.

What you can do:

     ►  Use the internet to visit formulary listings by plan and state

            http://www.epocrates.com

            http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp

     ►  If the person is on a medication that is not in the Part D plan formulary, then you can:

                 -  Check whether the medication is paid by California DHS such as benzodiazepines, barbiturates, over-the-

                    counter medications, weight loss or gain drugs, fertility drugs and prescription vitamins should be billed

                    through Medi-Cal.  Try to bill through Medi-Cal for these medications.  Medi-Cal continues to pay for these

                    drugs for Medi-Medis to the same extent that they did before January 1

                -  Request the medication as part of the required Part D plan “transition plan.” The PDP must provide the

                   prior medication, which the client had already been stabilized on, for a certain number of days even if not on

                   the formulary.  Almost all plans into which a Medi-Medi would have been auto-enrolled provide a 30-day 

                   supply.  A long list from Center on Medicare and Medicaid services (CMS) of ALL plans throughout the

                   country is on the Health Assistance Partnership link:                   

                   http://www.healthassistancepartnership.org/medicare/medicare-network-conference-calls/medicarecc010406.html 

          -  Remember that Medi-Medis can change plans at any time to a plan that may cover the medication but the

             change does not take effect until the following month.  Refer person to the Plan Finder at www.medicare.gov

             or to 1-800-MEDICARE to check for other plans

          -  Instruct the Medi-Medis to request an exception, asking the plan to cover the non-formulary.  A member is

             eligible for an expedited exception if the doctor so indicates or if waiting 72 hours would seriously

             jeopardize the person’s health

Issue #4   Medicare-only customers who are having problems paying for Medicare Part D drugs.

What you can do:

     ►  All low-income Medicare Beneficiaries WHO ARE NOT on Medi-Cal can get FREE HELP applying for the

           low-income subsidy to pay for most of their Part D prescription drug costs

     ►  Call Colleen Cook at the Consumer Center for assistance with enrolling into the low-income subsidy. 

           Contact her at 619.471.2650 or 1-877-734-3258 x 2650

This information has been adapted by the Consumer Center for Health Education and Advocacy (CCHEA)

CCHEA is located at:

          1475 Sixth Avenue, Fourth Floor

          San Diego CA 92101

          http://www.healthconsumer.org/SanDiego.html

          Phone number is 1-877-734-3258

          This flyer is up to date as of 1/9/06

For more info on facilitated enrollment, go to: 

http://www.healthassistancepartnership.org/medicare/medicare-network-conference-calls/medicarecc010406.html

OR

CMS' Website: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/