WHAT People with Medicare And Medicaid Should Expect From Medicare Part D After January 1, 2006

This New Year may bring more confusion than joy to the more than 6 million beneficiaries with both Medicare and Medicaid (“dual eligibles”) who will lose their Medicaid prescription drug coverage and be switched to Medicare’s Part D coverage on January 1, 2006.  Though the Centers for Medicare & Medicaid Services (CMS) announced contingency plans for those who fall through the cracks and gave assurances that the transition will go smoothly, dually eligible beneficiaries, their caretakers, and advocates are concerned that many will not be able to get the drugs they need this January.

The Center for Medicare Advocacy suggests several questions dual eligibles should ask, and several steps they can take, in order to ensure the smoothest transition possible:

In Which Plan Am I Enrolled?

NOTE:  Everyone who enrolls in a Part D plan will receive an Evidence of Coverage (EOC) document that gives pertinent plans’ phone numbers and procedures.  CMS has indicated that plans will not begin to mail out the EOC until the end of January.

NOTE:  Advocates should also check with their local communities.  Some cities and community mental health centers have established a process to provide prescriptions to duals who are denied drug coverage.

What Should I Do About My Retiree Health Insurance?

NOTE:  Each employer can set its own policies, and not all employers are being flexible.

Suppose My Drug Is Not on My Plan’s Formulary?

NOTE:  Detailed information about each plan’s Exception process will be included in the Evidence of Coverage document that plans are to mail to their enrollees. Beneficiaries will generally not be given this information at the pharmacy counter if the pharmacy determines that a drug will not be covered.  Rather, they will need to call the plan to find out how to file the Exception.  A beneficiary may request an Exception at the time of this initial inquiry, but the plan will not begin processing the Exception request until the doctor submits a supporting statement.

Copyright © Center for Medicare Advocacy, Inc. 09/10/2013