General Information

Medicare Part D Excluded Drug Classes

Federal law prohibits states from drawing federal Medicaid funds for drugs covered by Medicare Part D for dual eligible recipients (individuals who are both Medicare eligible and also eligible for some level of Medicaid prescription coverage). Under the Medicare Modernization Act that created pharmacy coverage under Part D, certain drugs can be excluded from coverage by the PDP. Texas Medicaid will continue to pay for a few categories of the drugs not covered by Medicare (wraparound benefit), including:

  • Nonprescription drugs (over-the-counter medications).
  • Some products used in symptomatic relief of cough and colds.
  • Some prescription vitamins and mineral products.

Changes to the Medicare Improvements for Patients and Providers Act of 2008

Section 1860D- 2(e)(2)(A) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was amended to include barbiturates “used in the treatment of epilepsy, cancer, or a chronic mental health disorder” and benzodiazepines. MIPPA further specified that these amendments apply to prescriptions dispensed on or after January 1, 2013.  Like any other prescription drug covered under the Part D benefit program, barbiturates and benzodiazepines must meet all other conditions for Part D drugs found in §423.100.

As of January 1, 2013, Texas Medicaid no longer covers barbiturates and benzodiazepines as part of the wraparound benefit for Medicaid clients who are also covered by a Medicare Part D plan (dual eligible). Pharmacies who submit claims for these drugs, for dual eligible clients, with a date of service on or after January 1, 2013, will be rejected (Error Code 41: “MEDICARERX covered drug class Call Medicare 1-800-633-4227”).

Facilitated Enrollment for Medicare-eligible Recipients

The point of sale Facilitated Enrollment process was designed to ensure that individuals with both Medicare and Medicaid, “dual eligibles,” who are not yet enrolled in a Part D prescription drug plan are still able to obtain immediate prescription drug coverage when evidence of Medicare and Medicaid eligibility is presented at the pharmacy.

The Facilitated Enrollment process permits a full-benefit, dual-eligible individual who presents a prescription at the pharmacy, and who the pharmacist discovers has not yet been auto-enrolled in a plan, to obtain a prescription at the subsidized co-payment amount before leaving the pharmacy and to be rapidly enrolled into a Medicare prescription drug plan (PDP) with a fully subsidized premium.

Pharmacies can help ensure the success of the program by utilizing the Eligibility Verification Transaction (E1) when a potential dual-eligible member presents a claim to the pharmacy. This Medicare transaction to Relay Health will help identify those members who are already enrolled in a PDP.

Additional information regarding the Facilitated Enrollment program can be found at the Centers for Medicare and Medicaid Services' website.

Medicaid no longer pays for clients opting out of Medicare Part D

Individuals who are eligible for both Medicare and Medicaid ("dual eligible") are automatically enrolled in a Medicare Part D prescription drug plan. Some dual eligible individuals may choose to disenroll, or "opt out," from Medicare Part D. This means the individual has disenrolled from Medicare Part D, not just the Part D plan.

Vendor Drug receives information about individuals who are eligible for Medicare Part D, but not enrolled in a Part D Plan. Medicaid will no longer be liable for the client's prescription drug coverage if the individual opts out of enrolling in a Part D Plan.

Message for Medicaid Recipients Becoming Eligible for Medicare Part D

Vendor Drug returns a message on paid claims for recipients who will soon become eligible for Medicare Part D. This message will be returned several months prior to the recipient's Medicare coverage effective date to alert the pharmacy that Medicare will become liable for the recipient's prescription drug coverage. The message will be returned in "Additional Message Information" (Field 526-FQ) and read "Part D liable for this client's Rxs no later than XX/XX/XXXX".

Please advise the recipient that Medicaid will no longer pay for prescriptions for Part D covered drugs as of the date included in the message. The recipient will need to choose a Medicare Part D plan by that date in order for their prescription benefits to continue as Medicaid will only be responsible for the Part D excluded drugs.