National Alliance on Mental Illness
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Tips at the Pharmacy Counter for Dual Eligible and Low-Income Subsidy Beneficiaries Subject to Plan Reassignment

December 21, 2007

Of particular concern to NAMI are individuals who are dually eligible for both Medicare and Medicaid or who qualify for the Low-Income Subsidy (also known as “Extra Help”) and are enrolled in a different plan for 2008.  CMS has taken steps to ensure that there is no gap in overall prescription drug coverage or access to refills in January. 

Any dual eligible or LIS recipient that received the blue colored reassignment letter from CMS needs to first read it carefully and contact their new prescription drug plan as soon as possible – every Part D plan is required to maintain an 800 customer assistance number.   

It is critical to:

  1. Take any paperwork you received from CMS or your Part D prescription drug plan to the pharmacy counter with you.  Participating pharmacists are required to have computer systems on site to verify enrollment and dual eligible or LIS status using a Medicare ID number – it is this dual eligible or LIS status that will ensure that accurate and minimal beneficiary cost sharing, 
  2. Check to make sure that all prescribed medications are on the new plan’s formulary – all Medicare drug plans are required to have “all or substantially all” antipsychotics, antidepressants and anticonvulsants on their formularies (lists of covered drugs),
  3. Inquire as to whether the new plan has any utilization management policies in place for any medications currently prescribed (prior authorization, step therapy, quantity limits),
  4. Remind the new plan that they are required to refill ANY AND ALL currently prescribed medication within the first 30 days of coverage after January 1, 2008 – THERE IS NO EXCUSE FOR A PHARMACY NOT TO REFILL ALL PRESCRIPTIONS FOR A DUAL ELIGIBLE BENEFICIARY, and
  5. Remind pharmacists, and your Part D prescription drug plan, that they cannot impose utilization management (prior authorization, quantity limits, step therapy, etc.) within the first 90 days of the new plan year (through the end of March).

It is also critical that all physicians prescribing to the dual eligible or LIS individual be notified before January 1 of the plan switch.  Likewise, the pharmacy that fills prescriptions for the dual eligible should be notified to see if they are part of the new plan’s network. 

Finally, if possible, it is STRONGLY recommended for dual eligibles to obtain refills of as many medications as possible before January 1 to avoid problems at the pharmacy counter in the early days of January 2008 as enrollment in the new prescription drug plan in verified and new membership cards arrive in the mail.