Steps to Resolving Part D Issues
| Full Benefit Dual Eligible (FBDE) Not auto-enrolled and has no current coverage through Part D | 1. Pharmacist runs E1 query (the E1 will return the RxBin, RxPCN, RxGrp, and RxID and 800# of the plan) 2. If E1 is successful, the medications should be ran through the plan system and billed appropriately and the beneficiary will pay co-payment 3. If E1 fails, pharmacy should verify that the person is eligible for both Medicare and Medicaid (Beneficiary presents cards) (Medicare dedicated pharmacy help line 1-866-835-7595) 4. Pharmacist enrolls beneficiary into Wellpoint fallback plan 5. Pharmacist will fill the prescription, submit the claim to Wellpoint, and charge a co-payment of $1/$3.10 6. Enrollment begins for Part D plan 7. FBDE must enroll immediately in a Plan for future drug coverage |
| Full Benefit Dual Eligible (FBDE) Auto-enrolled into plan with coverage but medication is not covered under the plan formulary | 1. Pharmacist will provide a temporary "first fill" of up to 30 days under the plan's new enrollee transition policy 2. Pharmacy may discuss switching the prescription to an alternative generic or medication that his on the plan's formulary 3. Beneficiary proceeds with exceptions and appeals process or changing plans to cover all medications |
| Full Benefit Dual Eligible (FBDE) Auto-enrolled into plan but has since changed plan prior to January 1 and is still showing up in system in auto-enrolled plan | 1. Pharmacy verifies current plan enrollment on system and processes claims using that plan's documentation or contact's FBDE's plan choice based on new plan's acknowledgement letter 2. If medications are not covered, initiates transition fill from plan 3. Beneficiary waits for plan switch to be effective to cover all medications for future drug refill needs, or 4. Finds new plan to cover all medications (FBDE can change monthly) 5. Enlists assistance of physician in exceptions/appeals process |
Full Benefit Dual Eligible (FBDE) Medicaid beneficiary whom is exempt from paying co-payments (assisted living residents, centers for the developmentally disabled and other alternative care arrangements, and home and community based waiver individuals) presents at counter with coverage but is being asked to pay co-payment
| 1. Pharmacy verifies current plan enrollment on system and processes claims 2. Plan identifies co-payment requirement 3. Pharmacy verifies Medicaid eligibility on Medicaid card - client must be dual eligible and the clients' monthly Medicaid card reads "NO co-pay." 4. Pharmacy may contact local state Medicaid office for clarification or verification of no co-payment amount 1-800-685-5456 5. Pharmacy bills Medicaid for co-payment amounts and beneficiary pays nothing |
Full Benefit Dual Eligible (FBDE)IF ISSUES CONTINUE TO GO UNRESOLVED, CMS REGIONAL KC OFFICE HAS IMPLEMENTED A COMPLAINT PROCESS FOR ALL BENEFICIARIES TO QUICKLY RESOLVE PROBLEMSTHE LOCAL STATE MEDICAID OFFICE IS WILLING TO TAKE THE INFORMATION FOR DUAL ELIGIBLES AND FAX TO THE CMS OFFICEState Medicaid Office Fax Number: 402-471-9092 Attn: Gary | 1. INFORMATION NEEDED: NAME |
| Low Income Subsidy Eligible (LIS) Has enrolled in plan but cannot confirm plan or subsidy amount at the pharmacy - beneficiary has letter from plan to support enrollment and letter from SSA to support subsidy determination amount | 1. Pharmacy verifies enrollment with letter and reflects amount of subsidy 2. Pharmacy bills plan with acknowledgement letter (RxBin, RxID, RxGrp) (or contacts the plan for those numbers) 3. Pharmacy informs plan of verification letter of LIS & co-pay amount 4. Pharmacy charges no more than $2.15/$5.35 co-payment reflected in the letter 5. Plan updates the system and pharmacy rebills the plan |
| Low Income Subsidy Eligible (LIS) Enrolled into a plan but waiting for determination on award | 1. Pharmacist runs medications through the plan enrolled into 2. Plan does not identify as receiving LIS help - pharmacy will charge for full price of the medication through the plan contract 3. Beneficiary saves receipts for medications filled 4. Once LIS subsidy acknowledgement is received, beneficiary contacts the plan and makes arrangements for changes in the system effective as of the date determined in the letter, as well as means for obtaining credit for past meds filled |
| Private Pay Enrolled into plan prior to January 1 but cannot be found in the plan or pharmacy system records. Beneficiary also has no acknowledgement letter to support enrollment (no ID, BIN, or RX number) | 1. Beneficiary should request small supply of medication until plan recognizes enrollment and is able to process claims 2. Beneficiary saves receipts for medications filled 3. Beneficiary contacts plan and makes arrangements for reimbursement for claims prior |
| Private Pay Enrolled in plan but some of medications prescribed not covered | 1. Pharmacist runs medications through system and obtains transition supply approval 2. Pharmacist may also discuss switching the prescription to a generic or alternative that is on the plan's formulary 2. Beneficiary pays for medications in transition supply 3. Beneficiary works with physician on exceptions/appeals process 4. Beneficiary makes switch to plan that does cover medications (only allowed to change plans 1 time after first enrollment into Part D plan) |
| Private Pay Enrolled into plan and has acknowledgement letter but pharmacy cannot verify enrollment in system | 1. Beneficiary presents letter to pharmacist 2. Pharmacist runs acknowledgement letter information (RxID, RxBIN, RxGrp) through the plan 3. Plan verifies enrollment (if plan denies enrollment, pharmacy should note to plan the verification letter in hand by the beneficiary and the plan will make the necessary changes) 4. Beneficiary fills medications at plan price |
IF SPECIFIC ISSUES CONTINUE TO GO UNRESOLVED, IMPLEMENT CMS REGIONAL OFFICE COMPLAINT PROCESSCMS COMPLAINT FORM AVAILABLE AT: ANSWERS4FAMILIES.ORG | 1. INFORMATION NEEDED: NAME |
