CMS is aware that there are instances in which a beneficiary may need to access drugs at an out-of-network pharmacy. Plans are required to assure that their enrollees have adequate access to drugs dispensed at out-of-network pharmacies when they cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy. Provided that such access to out-of-network pharmacies is not routine, we expect that plans would guarantee out-of-network access to beneficiaries when, for example they are: (1) traveling outside their plan’s service area and run out of or lose their covered Part D drugs or become ill and need a covered Part D drug, and cannot access a network pharmacy; (2) not able to obtain a covered Part D drug in a timely manner within their service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24/7 service; (3) filling a prescription for a covered Part D drug and that particular drug (for example, an orphan drug or other specialty pharmaceutical) is not regularly stocked at accessible network retail or mail-order pharmacies); (4) administered a vaccine covered by Part D in a physician’s office; and (5) provided covered Part D drugs dispensed by an out-of-network institution-based pharmacy while in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting. We will closely monitor out-of-network access to ensure that plans are adequately meeting enrollees’ out-of-network access needs.

Plans will have some flexibility to establish reasonable rules to assure that enrollees use out-of-network pharmacies appropriately. When an enrollee purchases a drug at an out-of-network pharmacy under these circumstances, he or she will pay the same cost-sharing as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy’s price and the network pharmacy price for that drug.

According to CMS, yes, and all information is accurate to what was provided to them by the plans. On November 7, detailed pricing data was added to the site, allowing users to compare drug costs and calculate total costs for the individual based on their medications. On November 14, the online enrollment center and a Spanish-language version of the Plan Finder tool were added to the site.  There are still some issues: slow site, links not functioning, but generally it’s working.  Some tips/new features:

• The online enrollment tool can assist in enrolling individuals in all plans except the 54 that chose not to participate in that option (waiting for clarification from CMS). Users can access the online enrollment form by clicking on an Enroll in a Plan button in five locations:
• On the Plan Finder homepage
• After searching the Plan Finder, each Plan detail page has a link to enroll
• On the Personalized search page
• On the detailed cost comparison page
• On the Medicare.gov personal plan finder page (for general Medicare plans)
• When doing a search based on medications, the tool will identify plans which cover the search medications and the user can click on the medication to get further detail about whether prior authorization, step therapy or quantity limits apply, and what copayment tier the medication is in. An ** in that box indicates a non-formulary medication.
• In late November, duals will be able to enter their personal information and automatically be able to compare the plan to which they’ve been autoenrolled to other plan options in their region.
• When conducting a personalized search for an individual, CMS admitted that dual eligibles are not differentiated from individuals eligible for the Extra Help, so the default information on copayments will show $2-5, rather than the $1-3 that will be applicable to most full benefit duals.
• The Plan Finder/Formulary Finder tool will only identify network pharmacies within a 50 mile radius of the individual. In rural states, this may (and is) limiting the choice of plans in some cases.
• When entering medications to conduct a personalized search, users are not able to enter the same medication in two different dosages (e.g., if an individual is on the same medication but different dosages in the morning and evening – and thus two separate prescriptions). CMS is aware and I await a response on how to get around that…

It is important to review the plans available in your region to see which drugs they will pay for since plans can choose to cover different medications. If possible, you should choose a plan that covers all of your medications. A Plan Comparison Web Tool will be available in October 2005 at http://www.medicare.gov. The tool will help you pick the drug plan that’s right for you.

CMS requires that each plan cover at least two drugs in each drug category. They are strongly encouraging plans to cover a majority of medications in the following categories: anti-psychotics, anti-depressants, and anti-convulsants. This is true for 2006, and may be re-evaluated in 2007.

Some drugs are not included in the new Medicare prescription drug benefit. These include: benzodiazepines (e.g. Ativan, Klonopin, Valium, Xanax), barbiturates, and drugs to treat eating disorders. If you take these medications, you should:

1. find other private manufacturer patient assistance programs to see whether they might cover your prescription, by contacting the Partnership for Prescription Assistance at 1-888-477-2669 or http://www.pparx.org; and
2. talk with your doctor about other medications that might work for you.

Consumers on extended release forms of medications will not get an automatic refill of their medication; they will need to ask for an exception from the plan.

Plans are allowed to make changes to their approved drug list at any time. However, they must give 60 days notice of these changes to enrollees who are taking that medication or provide enrollees with a 60-day supply of the medication they are removing from the approved drug list. The plan must also notify prescribing physicians and the Centers for Medicare and Medicaid Services

Medications needed urgently would be covered while a prompt exception process is completed. Plans are expected to supply to consumers at least a 30-day supply of medications. A physician or authorized representative can help the consumer with the appeals process. The provider should help facilitate the process

Find your network pharmacy (or pharmacies) listed on your plan materials or call the plan customer service line. Make sure the pharmacy you use now is part of the network for the prescription drug plan you joined.

Ask your doctor to call your prescription in and check that the medication is covered by your plan or bring in a paper prescription to the network pharmacy. Remember to bring your Medicare prescription drug plan card with you. If you do not have your card, you can give the pharmacist your Medicaid participant number or your Social Security number to check which plan you are enrolled in.

If your plan does not cover your medication or your plan requires a higher co-payment for your medication than for other similar medications, you may:

• Call your plan to ask them if the medication is not covered.
• Call your doctor or case manager to let them know.
• Discuss if you should seek an exception or change your medication. An exception is a formal decision by the plan to cover your medication or reduce your co-payment. If an exception is granted, it will last one year and will need to be requested again

You may have to pay a small fee (known as a co-payment or co-pay) when you pick up your prescription at the pharmacy. If you cannot afford the co-payment, ask your pharmacist if he or she can waive the amount. The government has said pharmacists can decide whether to require payment from you or fill your prescription drugs without the co-payment.

Other cost-sharing requirements may include co-insurance, which is a percentage of the cost of the prescription drug. Individuals with Medicare and Medicaid will not be required to make co-insurance payments.

If you cannot afford the cost-sharing requirements of your plan, there may be a state program to help cover your costs – contact your local State Health Insurance Program (SHIP) or the Partnership for Prescription Assistance to find out if such a program exists.

It is important to keep track of your out-of-pocket costs because, depending on your income level, the government will pay for most (or in some cases, all) of your prescription drug costs for the rest of the plan year, once you pay $3,600 in out-of-pocket costs. These costs do not include premium payments, but do include all prescription drug costs paid by you or another organization, including the federal government (e.g., Extra Help), State Pharmacy Assistance Programs (SPAPs), or private foundations or pharmaceutical manufacturer programs.