Contents:

• Medicare Part D Excluded Drug Classes
• Facilitated Enrollment for Medicare-eligible Recipients
• Opting out of Medicare Part D
• Message for Recipients Becoming Eligible for Medicare Part D

Resources:

• Medicare.gov
• Centers for Medicare & Medicaid Services
• Texas Department of Aging and Disability Services (DADS)
• TexasMedicareRx.org

Phone numbers:

• 1-800-MEDICARE (1-800-633-4227)
• Medicare Pharmacy Eligibility Line (1-866-835-7595)
  

Medicare Part D Excluded Drug Classes

Medicare Part D is a prescription drug benefit that began January 1, 2006. Part D offers optional drug coverage to all Medicare beneficiaries through private drug plans (PDPs) or Medicare Health Maintenance Organizations (HMOs).

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).
• Barbiturates (sedatives).
• Benzodiazepines (anti-anxiety agents).
• Some products used in symptomatic relief of cough and colds.
• Some prescription vitamins and mineral products.
  

Visit the Texas MedicareRx website to learn more about the basic-level Medicare prescription drug plans available in Texas.

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.

Pharmacies should ensure that the information entered is accurate as follows:

• The Cardholder ID (Field 302-C2) must contain the beneficiary's Medicare ID number. This can be found on the red, white, and blue Medicare card for traditional Medicare beneficiaries or the corresponding card from the Railroad Retirement Board (RRB). The Medicare ID number can be no less than 7 bytes and no greater than 12 bytes in length.
• The Patient ID (Field 332-CY) must contain the Medicaid ID. This field is a variable length field depending on the specifications of the state Medicaid program, but will not exceed 14 bytes in length.
• The Patient ID Qualifier (Field 331-CX) must equal '99' to properly identify the information in the Patient ID field.

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

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.

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.