RCPA - Rehabilitation and Community Providers Association


Medicare Prescription Drug Benefit Update
August 1, 2005

The Pennsylvania Department of Aging has scheduled a series of programs throughout the commonwealth to provide education on the Medicare Prescription Drug Benefit (Medicare Part D). These programs target mainly older adults and their significant support persons to help them to understand options available under Medicare Part D. The meetings will be hosted by representatives of the Apprise Program which provides health insurance counseling for Medicare beneficiaries. Information will be provided on Medicare Part D and its relationship with PACE and PACENET. For information on scheduled programs, select "Medicare Drug Benefit – Public Meeting Schedule" under "What’s Going On" at the Department of Aging web site (www.aging.state.pa.us).

The Medicare Rx Coalition met with representatives of the Department of Public Welfare (DPW) on July 20 to discuss transitional coverage as persons move from Medical Assistance (MA) to Medicare Part D. There is some uncertainty whether the Centers for Medicare and Medicaid Services (CMS) would adjust the "clawback"* to permit states to provide a 90-day supply of medications as the last fill in December before moving to the Medicare plan, instead of the usual 30-day fill. DPW and the Pennsylvania Health Law Project will seek clarification. For those otherwise eligible, the PACE program has suggested that PACE would exclude only those who have full Medical Assistance coverage. Once individuals lose MA drug coverage they would be eligible for PACE. PACE could then provide wraparound coverage for drugs not provided by the selected Medicare Prescription Drug Plan (PDP). PACE enrollment could also be considered "creditable coverage"** so that enrollees would not have to enroll in a PDP. MA intends to continue to cover classes of drugs that are not covered by PDPs. MA will not cover drugs that are not on the PDP formulary but are in classes covered by Part D. MA also intends to cover over the counter drugs (proton pump inhibitors and antihistamines) used in step therapy, although they are concerned that PDPs may choose not to cover these drugs or some generics if MA chooses to provide them.

There was lengthy discussion about whether to cut dual eligibles from MA eligibility as they transition to Medicare Part D on January 1 or later in the year, and whether to use benefits counselors to assist with the transition. There was also discussion of the transition from HealthChoices to Fee-for-Service and implementation of the Preferred Drug List prior to the transition to Medicare drug coverage. Please contact Betty Simmonds at PCPA with questions.

* clawback – state payment to CMS to defray a portion of the Medicare drug expenditures for full-benefits dual eligibles whose MA drug coverage is assumed by Medicare Part D.
** creditable coverage - prescription drug coverage that is determined to be equivalent to the standard Part D coverage.

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