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Medicare Rx Update:  CMS Issues Plan Detailing Transition of Dual Eligibles Into Medicare Part D

In a transition plan issued December 1, the Centers for Medicare and Medicaid Services (CMS) announced the development of a "Point of Sale Protection" for beneficiaries who are concurrently eligible for both Medicare and Medicaid (dual eligibles) that go to pharmacies before they have been auto-enrolled in a Medicare Part D plan. This will ensure full dual eligible individuals experience no gap in coverage when Part D commences on January 1, 2006.

If a beneficiary presents at a pharmacy counter with evidence of both Medicaid and Medicare eligibility, but without current enrollment in a Part D plan, the beneficiary will be able to leave the pharmacy with their prescriptions. CMS has contracted with Wellpoint, a national PDP, and Z-Tech to immediately follow-up to validate eligibility and facilitate enrollment into a Part D plan.  Read the CMS Fact Sheet on "Ensuring an Effective Transition of Dual Eligibles from Medicaid to Medicare Part D." (pdf, opens in a new browser window)

The CMS announcement of this new policy can be viewed by clicking on

Read a Question and Answer explanation on the transition to Medicare Part D. (pdf, opens in new browser window)

CMS Issues Clarification of Formulary Oversight Process and HPMS and Formulary Finder Tool Coordination 

On November 22, CMS issued a statement to inform partners of the outcome of a quality assurance (QA) analysis of formulary data from and the health plan management system (HPMS) for the six classes of clinical concern.  The analysis identified drug plan formularies that did not contain one or more drugs from these six classes of clinical concern -- including anti-psychotics, anti-depressants and anti-convulsants.  Lack of inclusion of these drugs on the Formulary Finder tool was primarily due to a technical issue between the information included in (HPMS) formulary files and the information available on the Formulary Finder.

This discovery of inadequate coverage is alarming given the importance the CMS "all or substantially all" coverage for Part D plan enrollees with severe mental illness and other chronic conditions.  This policy requires all Medicare drug plans to cover "all or substantially all" medications within 6 therapeutic categories (including anti-psychotics, anti-depressants and anti-convulsants).  This same policy limits the ability of these plans to impose restrictive practices such as prior authorization and "fail first" requirements with respect to medications in these classes. 

Plans were contacted to correct any deficiencies that existed in either data source (HPMS or The errors noted on the Medicare Prescription Drug Plan Finder tool are being fixed immediately by plan sponsors.   HPMS formulary files will be updated during the open period from December 12-16, 2005 where applicable.  CMS will continue to perform additional QA reviews to ensure that approved HPMS formulary files are being displayed appropriately to beneficiaries.

Any potential discrepancies on plan web sites or the Medicare Prescription Drug Plan Finder should be directed to CMS for further investigation.

Read the clarification statement issued by CMS on the Formulary Oversight Process. (pdf, opens in a new browser window)