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.

Yes. Duals can switch plans even though they receive letters indicating a plan into which they are being auto enrolled. And, those individuals can change up to once per month throughout the plan year. All other eligible beneficiaries may enroll in a plan and change that enrollment one time before May 15, 2006. After that time, those individuals will only be able to switch plans during the open enrollment period (November 15-December 31 each year) or in special circumstances, such as moving to another region, the plan stops offering benefits etc.

SNPs are able to limit their marketing and enrollment in Part D to one of three categories of beneficiaries: dual eligibles, institutionalized individuals, and those with long-term disability or chronic health conditions. SNPs with Medicaid managed care contracts are permitted by CMS to conduct passive enrollment of duals for coverage that begins January 1. 43 plans in 13 states (AZ, CA, CO, FL, KY, MN, NJ, OR, PA, TN, TX, UT, and WA) have been approved to do this. CMS criteria for the SNPs to conduct passive enrollment includes: existing contract as a Medicaid managed care provider, very similar provider network, identical pharmacy benefits manager, notice to beneficiaries of the ability to opt-out of the SNP, and no premium charged for Medicare Part A, B or D. Affected individuals should already have received a letter from their Medicaid managed care plan notifying them of this passive enrollment and allowing them to opt-out by the end of October. Those who opted out will also have a confirmation letter. Duals CAN switch out of these plans but will need to select and enroll into a different plan before January 1.
NMHA is aware that there is strong concern about the global benefit package for these SNPs; please call if you have further questions or specific detail in your state that would add to the body of knowledge about this issue.

Medicare beneficiaries will have two choices for how they get their prescription drug benefits:

1. Medicare beneficiaries who have their Medicare under a Medicare fee-for-service plan can enroll in an independent Medicare Prescription Drug Plan (PDP). These are private insurance plans that will charge monthly premiums.
2. Medicare beneficiaries who are in enrolled in a Medicare Advantage Plan, like an HMO (health maintenance organization) or PPO (preferred provider organization), will receive their prescription drug coverage through a Medicare Advantage Prescription Drug Plan (MA-PDP). Beneficiaries who are enrolled in Advantage plans that do not offer MA-PDPs will be able to enroll in independent PDPs.

Dual eligibles will be randomly enrolled, or auto-enrolled, into a low-premium Medicare PDP by CMS before December 31, 2005, and their Medicare prescription drug coverage will be begin on January 1, 2006. This is to ensure that there is no gap in drug coverage for these patients when their coverage under Medicaid ends on December 31, 2005, and the Medicare drug benefit takes over on January 1, 2006. On or about November 1, 2005, CMS expects to begin sending information to dual eligibles about which plan they will be enrolled in if they do not choose another plan before December 31, 2005. Duals may switch to a more appropriate plan than the one into which they were auto-enrolled any time before December 31, 2005, or on a monthly basis after Part D begins in January 2006.

CMS says it will randomly assign patients with both Medicare and Medicaid into one of the lower cost prescription drug plans available in their region.

Patients with partial dual eligibility, such as Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualifying Individuals (QI), as well as Supplemental Security Income (SSI) recipients and individuals with Medicare Savings Plans are automatically eligible for a low-income subsidy, or Extra Help, and will be automatically enrolled in a PDP by May 15, 2006, if they have not already enrolled themselves before that time.

• Initial enrollment runs from November 15, 2005 to May 15, 2006.
• If they sign up by December 31, 2005, coverage will begin January 1, 2006. If they join from January to May 2006, their coverage will begin on the first day of the following month.
• If a patient who does not already have as good or better coverage fails to sign up by May 15, 2006, he or she will have to wait until November 15, 2006, to enroll, and the premium cost will go up at least 1% per month for every month that he or she waits to enroll.
• Beginning on November 15, 2005, people with Medicare should be able to contact the prescription drug plans in their area directly to enroll, or may do so by calling 1-800-MEDICARE.

Patients should first determine what subsidies or programs they are eligible for, and then each individual must examine three key issues when selecting a plan:

• Drug coverage (including utilization management techniques such as prior authorization, generic substitution, fail-first or step therapy, and tiered co-pays)
• Accessibility of pharmacies
• Premium and co-pays

A chosen plan should have a drug formulary that includes all (or most) of the prescriptions currently being taken at the lowest available cost to the patient. Starting in October 2005, all participating drug plans should have all the information about their plans posted at www.medicare.gov.

Patients will need to know their income and asset levels (to see if they qualify for additional assistance; please see section on Low-Income Subsidies), their home address (to understand available PDPs in their area), and all the current medications they are taking to be able to compare plan formularies. Patient Assessment Chart

People with both Medicare and Medicaid (dual eligibles) and other Medicare beneficiaries who receive low-income subsidies:

• Can switch plans from November through December 2005, with coverage beginning on January 1, 2006, and monthly any time after that, with new plan coverage beginning on the 1st of the next month.
• If they switch into a plan that is not low premium, they will have to pay the difference between the low-premium plan and the one they have chosen.

All others with Medicare prescription drug plans

• Can only switch during the open enrollment period each year (November 15 – December 31).

Social security number, zip code, and date of birth may be required to obtain some specific information directly from a PDP. General plan information should be publicly accessible online at www.medicare.gov without any identification requirements, or by calling 1-800-MEDICARE.

Yes, if they are an appointed representative of the enrollee. Your patient is the only person, besides the prescription drug plan, who will have complete records of enrollment information. Your patient’s new network pharmacy may also have access to plan information, and so, if your patient loses his/her Part D card, he/she may be able to still get prescriptions from the pharmacy.

The treating physician, with a patient’s permission, may be able to call the pharmacy and verify a patient’s enrollment. The patient’s name and social security number would be required.

CMS has stated that by late October 2005 there will be a specific website available where physicians and their dual eligible patients can go to find out which plan the patients has been enrolled in. The information required to access the plan information is all contained on the patient’s Medicare beneficiary care.