Non-formulary drugs

Drugs not on a prescription drug plan (PDP) approved list.

Medically Necessary

Medical services or supplies that: are proper and needed for the diagnosis or treatment of a patient’s medical condition; are provided for the diagnosis, direct care, and treatment of a patient’s medical condition; meet the standards of good medical practice in the area; and are not chosen mainly for the convenience of the patient or doctor.

Medicaid

A joint federal and state program that provides medical coverage for people with low incomes and limited resources. Medicaid programs vary from state to state.

Prescription Drug Plan (PDP)

A private insurance plan that offers coverage for prescription drugs under Medicare, also known as a Medicare prescription drug plan.

Centers for Medicare and Medicaid Services (CMS)

The federal agency that runs the Medicare program, including the Medicare Prescription Drug Benefit program. In addition, CMS works with the States to run the Medicaid program.

Dual eligible (or duals)

A person who is eligible for both Medicare and Medicaid. CMS will automatically enroll dual eligibles in low-premium PDPs. If they choose to stay in a low-premium PDP, dual eligibles’ only cost for drugs will be a $1 co-pay for generic drugs and a $3 co-pay for brand-name drugs.

Formulary

A list of medications that a prescription drug plan covers (prior authorization by the Medicare prescription drug plan may be required).

Long-term care facility

A facility or medical institution that meets criteria outlined by the Social Security Act and which cares for residents with Medicare and/or Medicaid. Includes primarily skilled nursing homes.

Exception

The first phase of the appeals process; a formal decision by a Medicare prescription drug plan to cover a medication not on its formulary, or to reduce a co-payment for a drug not on the PDP’s preferred list. If the plan does not approve the exception, the appeals process can continue.

How to Maintain Continuity of Care During Transitions

Questions Answered

What should providers be aware of during the transition period to the new Medicare prescription drug program?

  • If a consumer is currently stabilized on a non-formulary drug, the plan should describe in detail how it will ensure that the consumer will continue to have access to that drug when there are known risks for negative clinical outcomes associated with its substitution.
  • A one-time emergency supply of a medically necessary, non-formulary drug may be available for consumers.
  • All PDP plans should have transition plans for new enrollees to ensure that emergency drugs are supplied.
  • If a service provider anticipates a problem with drug coverage, a supply of drugs determined by the physician to be medically necessary may be available. It appears that at least a 30-day supply of medications will be the standard used for emergencies.
  • Some states may also be able to prevent a lapse in coverage by filling a 90-day extended supply of prescriptions in December 2005 and still receive federal matching funds.

When will the transition from coverage of medication by Medicaid to the Medicare Prescription Drug Plans occur for dual eligibles?

Medicaid coverage ceases on December 31, 2005, and Medicare Drug coverage begins January 1, 2006.

What if the consumer's new plan's formulary doesn't include one or more of their medications on the formulary?

Enrollees should be able to review plan formularies with their providers starting in mid-October. This will hopefully allow consumers to choose a plan that better fits their medication needs. However, for consumers taking multiple medications, it may be that no one plan includes all of their drugs on its formulary. See section on Formularies.

Medicare Prescription Drug Plans are required to establish a transition process for new enrollees whose current drug therapies may not be included in their Plan's formulary. For example, plans may contact enrollees before coverage begins to identify their current medications and work out requests for exemptions or use of another medication that is on the formulary.

Should consumers refill their current prescriptions by December 31, 2005?

CMS recommends that Medicaid plans provide a temporary supply of medication during the transition period for dual eligibles. They say that at least 30 days is reasonable for consumers who first visit a pharmacy with a prescription for a drug that is not on the formulary of the consumer's new drug plan (a longer supply of 90-180 days is suggested for dual eligible consumers in long-term care facilities). The goal is to give the plan and/or enrollee enough time to contact the physician to choose another medication or to request an exception.

What happens when the consumer appears at the pharmacy after Jan 1? How will it be different from the way the consumer has filled prescriptions or refills previously?

It is important to note that each drug plan will have its own participating pharmacies and only these can be used by plan participants.
An enrollee will need to get their prescription filled at a pharmacy that participates with their plan. Consumers should also look at participating pharmacy choices when choosing a plan that's best for them.

Current as of 9-26-2005

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