Current information for pharmacist about the MassHealth Pharmacy Program Pharmacy Facts Number 18, March 13, 2006 MassHealth Pharmacy Program • Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan • Medicare Part D Prescription Drug Coverage Update As you know, on January 7, 2006, MassHealth began to allow pharmacies to bill MassHealth for Part D drugs when the pharmacy was unable to bill the Part D plan or the Wellpoint/Anthem point of sale contingency plan. On January 25, 2006, MassHealth began to require the pharmacy to submit an eligibility clarification code when submitting such claims to MassHealth for processing. On March 16, 2006, at 1:00 A.M., MassHealth will revert to processing claims for dual-eligible members under the same procedures that were in place on January 1, 2006. These procedures are described in Pharmacy Facts #15.* For information about billing the Wellpoint/Anthem point of sale contingency plan if a dual-eligible member is not yet enrolled in a Medicare prescription drug plan, call 1-800-662-0210. Prior editions of the Pharmacy Facts can be found on the MassHealth Web site at: www.mass.gov/masshealth/pharmacy. In accordance with state legislation signed on December 30, 2005, MassHealth will provide limited assistance for Part D drugs for dual-eligible and Prescription Advantage members when a Medicare Part D plan will not cover the medication at the time the prescription is presented. Through June 30, 2006, the state will pay for a one-time 30-day supply of medications that are not covered by the member’s prescription drug plan at the time the prescription is presented at the pharmacy, followed by a one-time 72-hour supply of the same medication, if the member’s prescription drug plan will still not cover the medication the next time the prescription is presented. Effective July 1, 2006, the state will no longer pay for a one-time 30-day supply, but will pay for a one-time 72-hour supply of medications that are not covered by the member’s prescription drug plan at the time the prescription is presented. Attached to this fax are English and Spanish versions of a legislatively required notice for members who receive the mandated supplies. The notice explains how the member can obtain the medication in the future. The notice is only required for the legislatively mandated supplies, and does not apply to drugs excluded from Medicare Part D coverage that the Commonwealth continues to pay for as a MassHealth-covered benefit (e.g., benzodiazepines). Further information about this so-called “formulary wrap-around benefit” can also be found in Pharmacy Facts #15.* The state will also assist with Medicare prescription drug copayments for MassHealth members who are charged $2 for generic drugs and $5 for brand-name drugs. The procedures for this “copay wrap-around benefit” are described in Pharmacy Facts #17. MassHealth will deny copay wrap claims submitted for greater than $5. Part D plans cannot charge MassHealth members more than $5, and if they do so, you need to contact the Part D plan to override the higher copayment charge. Beginning on Monday, March 13, 2006, MassHealth will include the Medicare Prescription Drug Plan (PDP) enrollment information we have in the response message you receive when a claim denies due to the member's Medicare Part D eligibility. If POPS has the BIN and Processor Control Number of the PDP, the response message will be formatted similarly to the response from the eligibility intermediary. If the BIN and Processor Control Number is unknown to POPS, the response message will include an alternate MassHealth carrier identification number, telephone number, and carrier name similar to other third-party reject messages. * Pharmacy Facts #15 indicates that the legislatively mandated assistance will end on June 30, 2006. While coverage for one-time 30-day supplies will end on June 30, 2006, the state will continue to pay for one-time 72-hour supplies. Please direct any questions or comments (or to be taken off of this fax distribution) to Victor Moquin of ACS at 617-423-9830. Important Information for Medicare Enrollees Who Have MassHealth or Prescription Advantage The drug you just received was a one-time, 30-day supply paid for by the state. This drug was not covered by your new Medicare prescription drug plan. After this one-time, 30-day supply, the state may also cover a one-time, 72-hour supply of your drug. After that, MassHealth and Prescription Advantage will no longer cover this drug. To get your drug in the future, here are some steps you should take right away: 1) Talk to your doctor. Find out if there is a different drug that is covered by your Medicare drug plan and that will work as well as the drug your doctor prescribed. If not, then you or your doctor can request an “exception.” • All Medicare and Medicare Advantage drug plans must have a process for requesting “exceptions.” If your drug plan approves the exception, it will pay for your drug. If it denies the exception, you can appeal that decision. • For information on the Medicare drug plan exceptions and appeal process, call Medicare at 1-800-MEDICARE (1-800-633-4227). For help with exceptions and appeals, you can also call the Medicare Advocacy Project at 1-800-323-3205. 2) Find out if a different Medicare drug plan covers all of your drugs. Call Medicare at 1-800-MEDICARE (1-800-633-4227) to find out what plans cover the drugs you take. You can also call the SHINE program at 1-800-AGE-INFO (1-800-243-4636) or MassMedLine at 1-866-633-1617 for help in picking the right plan. Be sure to find out the cost of the plan, the list of drugs covered by the plan, and if your pharmacy is part of the plan. • Call the new plan to enroll. You do not need to call the old plan. • If you are a MassHealth member or in a nursing home, you may change plans at any time, effective the first day of the next month. • If you are a Prescription Advantage member, you can change plans once between January 1 and May 15, 2006. The next time you can change plans will be the next open enrollment period, which is November 15 through December 31, 2006. Note: If you do not know which Medicare drug plan you are in, you can find out by calling Medicare at 1-800-MEDICARE (1-800-633-4227). Or you can use Medicare’s online tool to compare drug plans at www.medicare.gov. Prescription Advantage members can also call Prescription Advantage Customer Service at 1-800-AGE-INFO (1-800-243-4636). Call one of the following toll-free numbers for more information: • Medicare: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 for people with partial or total hearing loss); www.medicare.gov • MassHealth Customer Service: 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss) • SHINE: 1-800-AGE-INFO (1-800-243-4636), press 2; www.medicareoutreach.org • MassMedLine: 1-866-633-1617 • Medicare Advocacy Project (help with exceptions and appeals): 1-800-323-3205 (TTY: 617-371-1228 for people with partial or total hearing loss) • Prescription Advantage: 1-800-AGE-INFO (1-800-243-4636), press 1 (TTY: 1-877-610-0241 for people with partial or total hearing loss); www.800ageinfo.com MEDI-D-PH (03/06) Información importante para los afiliados de Medicare que tienen MassHealth o Prescription Advantage El medicamento que usted acaba de recibir es un suministro para 30 días, pagado por el estado por única vez. Su nuevo plan de Medicare para medicamentos con receta no cubre este medicamento. Después de este suministro único para 30 días, el estado podría pagar otro suministro único de su medicamento en cantidad suficiente para 72 horas. Después de eso, ni MassHealth ni Prescription Advantage cubrirán este medicamento. Estos son los pasos que debe seguir inmediatamente para recibir su medicamento en el futuro: 3) Hable con su médico. Investigue si existe otro medicamento que esté cubierto por su plan de medicamentos de Medicare y que funcione tan bien como el que le recetó su médico. Si no existe ese medicamento, usted o su médico pueden solicitar una "excepción". • Todos los planes de medicamentos de Medicare y Medicare Advantage deben tener un proceso establecido para solicitar “excepciones”. Su plan pagará su medicamento si aprueba la excepción. Si rechaza la excepción, usted puede apelar esa decisión. • Si desea recibir información sobre las excepciones del plan de Medicare para medicamentos y el proceso de apelación, llame a Medicare al 1-800-MEDICARE (1-800-633-4227). Si desea recibir ayuda con las excepciones y apelaciones, puede comunicarse al Medicare Advocacy Project (Proyecto de Abogacía de Medicare) al 1-800-323-3205. 4) Investigue si otro plan de Medicare para medicamentos cubre todos sus medicamentos. Llame a Medicare al 1-800-MEDICARE (1-800-633-4227) para averiguar qué planes cubren los medicamentos que usted toma. También puede comunicarse al programa SHINE al 1-800-AGE-INFO (1-800-243-4636) o a MassMedLine al 1-866-633-1617 para que le ayuden a elegir el plan más adecuado. Asegúrese de averiguar el costo del plan, la lista de medicamentos que cubre el plan, y si su farmacia forma parte de él. • Llame al nuevo plan para inscribirse. No tiene que llamar al plan que tenía anteriormente. • Si usted es afiliado de MassHealth o está en una centro de enfermería, puede cambiar de plan en cualquier momento, y el nuevo plan entrará en vigencia el primer día del mes siguiente. • Si usted es afiliado de Prescription Advantage, puede cambiar de plan una vez entre el 1 de enero y el 15 de mayo de 2006. La próxima vez que usted podrá cambiar de plan será en el siguiente periodo de inscripciones, el cual corre desde el 15 de noviembre al 31 de diciembre de 2006. Nota: Si usted no sabe en qué plan de Medicare para medicamentos está inscrito, puede averiguarlo llamando a Medicare al 1-800-MEDICARE (1-800-633-4227). O puede usar la página de Medicare en la red para comparar planes para medicamentos en www.medicare.gov. Los afiliados de Prescription Advantage también pueden llamar al Departamento de atención al cliente de Prescription Advantage al 1-800-AGE-INFO (1-800-243-4636). Llame a uno de los siguientes números gratuitos para obtener más información: • Medicare: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 para personas con sordera parcial o total); www.medicare.gov • Centro de servicios al cliente de MassHealth: 1-800-841-2900 (TTY: 1-800-497-4648 para personas con sordera parcial o total) • SHINE: 1-800-AGE-INFO (1-800-243-4636), y marque el 2; www.medicareoutreach.org • MassMedLine: 1-866-633-1617 • Medicare Advocacy Project (para recibir ayuda con excepciones y apelaciones): 1-800-323-3205(TTY: 617-371-1228 para personas con sordera parcial o total) • Prescription Advantage: 1-800-AGE-INFO (1-800-243-4636), y marque el 1 (TTY: 1-877-610-0241 para personas con sordera parcial o total); www.800ageinfo.com MEDI-D-PH-SP (03/06)