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Help With Medicare Part D Challenges
January 13, 2006

PCPA is providing information to assist members with the challenges that have developed as Medicare Part D, the Medicare Prescription Drug Benefit, is implemented. The Department of Public Welfare (DPW) and the Centers for Medicare and Medicaid Services (CMS) are extremely concerned with problems that have arisen. The Office of Mental Health and Substance Abuse Services (OMHSAS) has developed a question and answer document for Medicare Part D. CMS has developed a “What if…” document to answer questions. The Pennsylvania Health Law Project (www.phlp.org/Medicare%20Part%20D.asp) has fact sheets that may be helpful as providers assist individuals with access to needed medications. Following are suggestions providers may find helpful.

  • Some dual eligible individuals have been charged large co-pays for medications when they should have been charged no more than $5. On January 12 Governor Rendell announced that Medical Assistance will pay co-pay amounts over $5 for dual eligible individuals who are eligible for low income subsidy with co-pay amounts of $1-5. Guidelines for this process are available on the DPW web site (www.dpw.state.pa.us/Resources/Documents/Pdf/ExcessiveCopaysForPartDLetterFINAL.pdf).
  • CMS instituted a transition plan requiring pharmacies to provide a one-time 30-day refill for prescription drugs during the initial implementation period (www.phlp.org/New%20Medicare%20Law%20Pdf%20Files/Transition%20policy%20reminder%201%2006%2006%20FINAL.pdf).
  • According to OMHSAS, if the pharmacist refuses to fill the prescription the individual should insist that the prescribing physician be contacted and the reason for denial explained.
  • Some individuals who do not have an Access card, often those who were enrolled in HealthChoices, should contact the County Assistance Office to obtain a card.
  • Contact Medicare at 800–MEDICARE to identify which plan an individual is enrolled in.
  • Contact the applicable plan to resolve problems when possible.
  • Contact the Medical Assistance call center (866-542-3015) for questions and problems related to dual eligible persons. Information is available at www.dpw.state.pa.us/Business/MedicarePartD.
  • Contact APPRISE at 800-783-7067 for enrollment information.
  • Dual eligible individuals not enrolled in a plan can enroll in the Part D Point of Sale Protection Plan at the pharmacy, although this system has been extremely stressed. Individuals will need at least one photo identification card to enroll.
  • Community mental health centers can contact the chief executive officer of the state hospital in the applicable region for assistance in emergency situations for individuals to receive a 7-day supply of medications. The process involves the state hospital authorizing payment to a local Medicare/Medical Assistance enrolled pharmacy.
  • The Pennsylvania Health Law project may be able to help dual eligible individuals who have problems with enrollment or access to needed medications (800-274-3258).
  • Please contact Betty Simmonds to discuss situations that cannot be resolved using these resources.

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