Mental Health Part D News Alert

December 21 , 2006

Presciption & Pharmacy Preparation for January from CMS...How to make the changeover to the new Plan Year a little smoother:  3 steps beneficiaries should take to help at the pharmacy.

January preparation… the best medicine for  beneficiaries

January is the busiest month in the pharmacy  due to changes that millions of Americans make to their insurance coverage  that take effect in January.  For this reason, we have been encouraging  Medicare beneficiaries to help pharmacists by taking 3 easy  steps:

1. If you have a prescription or refill that can be filled at or  near the end of 2006, don’t wait… get it filled before January  1.  Taking care of refills in December will reduce the  burden on pharmacists and may reduce the time a beneficiary has to wait to get  the prescription filled in January.  
2. If you have a prescription to be filled in early January and you  have changed plans or have not used your new plan coverage, make sure you bring your new insurance card (and proof of Medicaid or LIS eligibility if applicable) to the pharmacy with your  prescription.  Providing correct and complete information to the pharmacist will make it easier for the pharmacist  to serve beneficiaries which will reduce prescription fill times and delays at  the pharmacy.  Beneficiaries should be sure to have their Plan ID card, Medicare and/or Medicaid card, and a Photo ID (See Quick  Tips http://www.cms.hhs.gov/partnerships/downloads/firsttripenglish.pdf for the first trip to the pharmacy).  People who been  approved for the low-income subsidy (LIS) should also bring a copy of the  yellow automatic enrollment letter from Medicare, an approval letter from the  Social Security Administration, or other proof that they qualify for extra  help.
3. If you have not received your new insurance card from your new  plan, make sure that you bring a confirmation letter or some other proof of coverage from your new plan with you to the pharmacy in  January.Because people may enroll in Part D through the  end of December, some late enrollees may not receive their plan ID card by the  first day of the New Year (see Tip  Sheet http://www.cms.hhs.gov/States/Downloads/NoMembershipCard.pdf ). In this case, beneficiaries should bring an  acknowledgement or confirmation letter from the plan, or an enrollment  confirmation number received from the Plan.  If the person has not received any enrollment materials, the pharmacist may be  able to submit an  E1 query, or call the  dedicated pharmacy enrollment/eligibility helpline  (1-866-835-7595)  or 1-800-MEDICARE to identify the plan in which the person is  enrolled.  As a last resort, the beneficiary may have to pay  out-of-pocket for the prescription and send receipts to the plan.  

Point of Sale Option improved for  2007…

CMS  will continue to contract with WellPoint to provide Point-of-Sale Facilitated  Enrollment (POS FE) for those qualified low-income beneficiaries who  are not enrolled in a Part D plan.  To avoid submission of ineligible  claims, CMS and Wellpoint will include tighter front-end edits to check for  eligibility at the POS.  These edits will allow the pharmacist to know  how to properly adjudicate claims at the POS rather than submitting the claim  through WellPoint POS FE only to have it reversed weeks or months later due to ineligibility.

CMS  anticipates that far fewer beneficiaries will need to use the POS in 2007  because the vast majority of dual eligibles are already enrolled in a Part D  plan.  In addition, CMS and States have worked to prospectively identify  beneficiaries so they can be enrolled in a Part D plan as of the effective  date of their dual eligibility.  Pharmacists should review the POS Tip  Sheet for further information on the 2007 POS program (http://www.cms.hhs.gov/States/Downloads/pos4steps.pdf).