Helpful Information to Share with Pharmacists Serving Medicare Beneficiaries

1. If No Evidence of Part D Plan Enrollment

To file a claim with a Part D plan in order to fill a prescription, the pharmacist needs the "4Rx" information (RxBIN-RxPCN-RxGrp-RxID). This information is often located on the beneficiary's plan membership card (that should arrive by mail around three weeks after enrollment) and/or the beneficiary's enrollment acknowledgement letter (that should arrive by mail around one week after enrollment).
If the pharmacist does not have access to this information because the patient does not have the membership card or the plan enrollment acknowledgement letter, or if the letter does not include the 4Rx information, the pharmacist can submit an E1 transaction to determine the beneficiary's plan information.

If the E1 query comes back with the 4Rx information, the pharmacist should be able to file the beneficiary's claim and fill the prescription.
If the E1 query does not return the relevant information (or enough of the relevant information) but does give plan name or phone number, the pharmacist should call the Part D Plan help desk for the 4Rx information. The help desk number should be available through the E1 query, or the pharmacist could call the plan's customer service number.

If the plan help desk gives the 4Rx data, the pharmacist should be able to file the beneficiary's claim.
If the plan's help desk does not provide the 4Rx information, if there is a long hold time to speak with the help desk, or if the claim is not able to be processed, the pharmacist can call the CMS dedicated pharmacy line at (866) 835-7595.

If the pharmacist obtains the relevant beneficiary information from CMS, it can be used to file the beneficiary's claim and fill the prescription.

If the CMS dedicated pharmacy line does not resolve the problem, the pharmacist should contact the CMS Regional Office Part D Assistance Center.

Note: For more information about this process, see the following CMS letter to Part D plans as well as the NDCHealth/Per-Se letter to pharmacists.

2. If No Evidence of Part D Plan Switch

All Medicare beneficiaries enrolled into a Part D plan are allowed at least one opportunity to switch plans before May 15, 2006. Some Medicare beneficiaries, including the full duals (both Medicare and Medicaid) and those in a Medicare Savings Program (QMB, SLMB, and QI), are allowed to switch Part D plans on a monthly basis throughout the plan year. It has become apparent that at times the beneficiary's data is not updated in real time in the plans' computer systems and therefore new enrollment information does not follow the beneficiary to the new plan promptly.
If a Medicare beneficiary has switched Part D plans and the pharmacist is unable to identify the 4Rx for the new Part D plan through an membership card or acknowledgement letter, the pharmacist should make an E1 transaction to determine the beneficiary's new plan information.
The process for filing a beneficiary's claim with a new Part D plan would then follow the procedures outlined above, "If No Evidence of Part D Plan Enrollment".

3. If No Record of Low-Income Subsidy (LIS) Status

Some Medicare beneficiaries are entitled to extra help for paying for the costs associated with Part D plans. Full duals (both Medicare and Medicaid), those in a Medicare Savings Program (QMB, SLMB, and QI), as well as individuals with Supplemental Security Income automatically qualify for the low-income subsidy (LIS). Other low-income individuals (with limited resources) who do not fit into the above categories have applied for this extra help to pay for the costs associated with a Part D plan. Medicare beneficiaries who have been granted LIS should have reduced costs associated with the Part D plan— including the monthly premium, the annual deductible, and copayments for each prescription filled.
The pharmacist should file claims with Part D plans for beneficiaries who receive the LIS exactly the same as for beneficiaries without the LIS. If the cost-sharing information reported back by the system is above $5.00 for a prescription, it is likely incorrect. For a detailed chart of exact cost sharing amounts for all categories of LIS recipients, see the Extra Help for Low-Income Beneficiaries (2007) Chart.
If the system does not return LIS co-pays in accordance with the patient's LIS status, the pharmacist should first contact the Part D plan help desk to clarify the LIS status of the Medicare beneficiary.

The Part D plan help desk should be capable of arranging edits on the system to enable patients to pay correct LIS-approved copayments if the pharmacist tells the Part D help desk that the beneficiary has a prior history of Medicaid billing for their prescriptions filled at this pharmacy. If necessary, the pharmacist also can verify the LIS status of the beneficiary by asking the beneficiary to show any of the following documents:

Medicaid card
Copy of current Medicaid award letter with effective dates
State eligibility verification system (EVS) queries (interactive voice response, online)
LIS notice from Medicare or the Social Security Administration that says the person has been approved for extra help

If the Part D plan help desk is unable to verify exact level of LIS, CMS has stated that the fallback cost sharing should be $2.00 for generic drugs and $5.00 for brand name drugs. If requested by the Part D plan help desk, the pharmacist may fax the documentation mentioned above to the plan to support the assertion of LIS status. See CMS's January 13, 2006 letter to Part D plans for more details.

If the help desk is unable to help verify LIS status, the pharmacist should call the CMS dedicated pharmacy line at (866) 835-7595.
If the dedicated line is unable to help, the pharmacist should contact the CMS Regional Office Part D Assistance Center.

4. If No Transition Prescription Fill

CMS indicated in its Transition Guidance that all Part D Plans should offer all beneficiaries a 30-day transition one-time supply of their medications regardless of formulary restrictions.
For those dual eligible beneficiaries (with both Medicare and Medicaid) who have not been auto-assigned into a Part D Plan, CMS has also established a fallback plan (WellPoint/Anthem/Unicare) to provide these beneficiaries access to their prescriptions. The procedure for utilizing this Point of Sale process (WellPoint/Anthem/Unicare) is available. It is important to note that the standard WellPoint/Anthem/Unicare transition one-time prescription fill is 14 days, after which plan auto-enrollment should be confirmed, or the patient should be enrolled through the WellPoint/Anthem/Unicare Point of Service Solution into a Part D plan.
If pharmacies have difficulty receiving authorization from a Part D plan for a transition fill of a medication, the pharmacist may take these actions:

Contact the Part D plan help desk, which should be able to clarify the process by which a pharmacist can override the formulary restrictions set by the plan.

If the plan's help desk is unable to provide information to the pharmacist about the plan's transition process, the pharmacist may remind the plan that CMS has stated that plans must give a transitional supply of all Medicare Part D-covered drugs to new enrollees.

Please note that CMS has directed the plans to provide an expedited transition process through a letter and a reminder.

If necessary, the pharmacist may consider faxing the two letters above to the Part D plan to expedite the transition process.
If the Part D plan's help desk does not assist the pharmacist in providing a one-time transition fill of the beneficiary's medication, if there is a long hold time to speak with the help desk, or if the claim is not able to be processed, the pharmacist can call the CMS dedicated pharmacy line at (866) 835-7595.

If the pharmacist obtains the relevant beneficiary information from CMS, it can be used to file the beneficiary's claim and fill the prescription.

If the dedicated pharmacy line does not resolve the problem, the pharmacist should contact the CMS Regional Office Part D Assistance Center for casework solutions.

At the time the enrollee gets the transitional supply, the pharmacist should advise the enrollee about the reason the one-time transition fill was necessary.

If the reason for the transition fill is a utilization management protocol (e.g., step therapy, quantity limits, and prior approval), the enrollee should speak with his doctor about adhering to the plan's utilization management process.
If the reason for the transition fill is that the drug is not on the Part D plan's formulary, the enrollee should speak with her doctor about switching drugs or requesting an exception to the Part D plan's formulary.

Note: Drugs excluded from Part D coverage may still be covered for duals by the state Medicaid program. Every state is covering at least some of the excluded drugs. Information about which state Medicaid programs are covering which excluded Part D drugs is available.

5. Problems Unique to Long-Term Care (LTC)

If there is no evidence of plan enrollment for a Medicare beneficiary in long-term care, see Situation 1.
All Medicare beneficiaries residing in a long-term care facility are permitted to switch Part D plans as often as monthly, effective the first day of the following month. If there is no evidence of a Part D plan switch for a Medicare beneficiary residing in long-term care, see Situation 2.
After the first full month of residence in certain long-term care facility, there should be no Part D cost sharing for Medicare beneficiaries who are also on Medicaid. [1] Accordingly, any Medicare beneficiary who was a resident of a long-term care facility and on Medicaid on December 31, 2005, should have no cost sharing of any kind under Part D.

If there is no evidence of the low-income subsidy or if cost sharing is applied to these beneficiaries, see Situation 3.

Coordination of Medicare payments for residents' medications, especially those administered through durable medical equipment (DME) has become more significant than ever before due to the implementation of Part D.

CMS has created a chart of Part B versus Part D coverage issues.
CMS has released guidance on Medicare Part B versus Part D coverage issues.

If this information does not clarify the correct Medicare billing entity, the pharmacist should call the Part D plan's help desk.
If the Part D plan's help desk is not able to clarify the correct Medicare entity to bill, the pharmacist can call the CMS dedicated pharmacy line at (866) 835-7595.
If the dedicated pharmacy line does not resolve the problem, the pharmacist should contact the CMS Regional Office Part D Assistance Center for casework assistance.

6. Incorrect Part D Cost Sharing Charged to Beneficiary

A beneficiary who has paid more for a prescription than the amount that the plan has established for her is entitled to request a refund for the excess charges. The process for requesting a refund from the Part D plan is called a Coverage Determination. HAP has created a toolkit (scroll down to Toolkit II) with information about the process for requesting a Coverage Determination as well as sample coverage determination letters.

For information about Helpful Information to Share with Pharmacists Serving Medicare Beneficiaries, please contact Kelly Brantley at kbrantley@healthassistancepartnership.org.

[1] Dually-entitled residents do not pay any cost sharing amounts to their Part D plans if they reside in the following long-term care facilities: skilled nursing facilities, nursing facilities, inpatient psychiatric hospitals, or intermediate care facilities that are residential facilities for developmentally disabled adults (called "ICF/MR"). Residents of other long-term care institutions (including assisted living facilities, group homes, and board and care homes) will incur costs associated with their Part D plans.