Medicare Part D Frequently Asked Questions (2022)

For People With Both Medicaid and Medicare

  • General Questions
  • Low Income Subsidy (LIS) Questions
  • Provider Questions
  • Enrollee Questions
  • Pharmacist Questions
  • Nursing Homes Questions

General Questions

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  1. What is Medicare Part D?

    The Medicare Modernization Act (MMA) of 2003 added prescription drug benefits for Medicare beneficiaries and is known as Medicare Part D. Medicare Part D offers prescription drug coverage through Medicare. A Medicare Part D eligible individual is one who is entitled to or enrolled in Medicare benefits under Part A and/or Part B.

  2. Who are dual eligibles?

    Dual eligibles are people who have both Medicare and Medicaid.

  3. How are dual eligible enrollees affected by the Medicare Part D Prescription Drug Program (PDP)?

    Dual eligibles receive their prescription drug coverage through Medicare rather than through the Medicaid program. Medicare Part D replaces Medicaid as the pharmacy coverage for dual eligible enrollees.

  4. What happens if an enrollee has insurance coverage through their employer or union along with Medicare and Medicaid?

    If enrollees do not participate in a Medicare prescription drug plan, they may lose all their Medicaid benefits. However, some people on Medicare and Medicaid may receive a letter from their employer or union stating that if they enroll in Medicare Part D they will lose the health care benefits provided by the union or employer. If an enrollee has received this letter, they may disenroll from the Medicare Prescription Drug program by calling 1-800-MEDICARE (1-800-633-4227). They must also give a copy of this letter to their Medicaid worker in order to continue receiving Medicaid benefits.

  5. How can I find out which plan a dual eligible is enrolled in?

    Contact Medicare at 1-800-MEDICARE (1-800-633-4227), refer to the CMS Plan Finder at https://www.medicare.gov/find-a-plan/questions/home.aspx or refer to the letter sent to the enrollee by CMS containing enrollment information. Information from the enrollee's Medicare card will be necessary. This includes: name, DOB, effective dates of Medicare Part A & B and the beneficiary's Medicare ID #. Pharmacies may also be able to help.

  6. Who can assist enrollees with enrollment in a Medicare prescription drug plan?

    Enrollees may obtain assistance in finding a plan to better match their needs by calling 1-800-MEDICARE (1-800-633-4227) or by going to the CMS website https://www.medicare.gov/find-a-plan/questions/home.aspx or by contacting HIICAP at 1-800-701-0501. Only the enrollee, or their legally authorized representative, can actually enroll the enrollee in a PDP but anyone, especially their physician or pharmacist, can help them understand and choose their plan.

  7. Are there certain plans duals should enroll in?

    CMS has identified certain plans as "benchmark" plans. Dual eligible enrollees should be encouraged to join these plans because they will not be responsible for any additional monthly premiums. If they choose to join other "non-benchmark" plans, they will become responsible for monthly premium payments.

  8. How can community-based groups assist full benefit duals in selecting a better plan?

    Community-based groups can assist in educating duals by providing information that will help the dual eligible choose a plan that best meets their needs. For example, community based groups can advise dual eligibles about the benefit of enrolling in the benchmark plans (no premiums). They can advise the enrollee about what plans cover the drugs currently used by the enrollee, the plan's exception and appeal processes, utilization controls such as prior authorization, and what plans include the pharmacy that the enrollee wants to use. These groups, however, cannot direct the enrollee into a specific plan or enroll them in a plan.

  9. Can the PDP enrollee continue to fill their prescription at any pharmacy as they did with the Medicaid program?

    No. Each plan has a pharmacy network. The dual eligible enrollee should verify that the pharmacy they intend to use is in the network of the PDP they are enrolled in to ensure that their prescriptions will be covered. Enrollees can review the list of participating network pharmacies by checking with their drug plan, by contacting Medicare, or calling their pharmacy.

  10. What is a formulary?

    A formulary is a list of medications that are covered by a prescription drug plan.

  11. Do all prescription drug plans have a standard formulary?

    No. Each plan has their own formulary which may include a variety of utilization management tools such as: prior authorization, step therapy, and quantity limitations. These formularies can change, but when they do, plans are required to notify their enrollees who use an affected drug, at least 60 days prior to the change.

  12. Who is responsible for assuring patient access to their medications?

    When beneficiaries first join a plan, they may be taking medications that are not on their plan's formulary, meaning that their new plan does not cover them. However, the Centers for Medicare and Medicaid Services (CMS) has directed Part D plans to provide a temporary "transitional" supply of drugs to new beneficiaries who are taking drugs that the plans would not normally cover.

    Prescribers, pharmacists, discharge planners, and the enrollee should contact plans and ask about their transition process.

Low Income Subsidy (LIS) Questions

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  1. I have both Medicare and full Medicaid coverage. Do I need to apply for extra help to pay for Medicare prescription drug coverage?

    No. The "extra help" is a subsidy that people with Medicare and Medicaid automatically qualify for without having to complete an application.

  2. If I am enrolled in a Medicare Savings Program, do I have to apply for "extra help"?

    If you do not have Medicaid, but Medicaid pays your Medicare Part B premium, you automatically qualify for "extra help" and you don't need to apply.

  3. If I do not qualify for NYS Medicaid or the Medicare Savings Program, can I still qualify for "extra help"?

    You may still be eligible for "extra help" to pay for the Medicare prescription drug plan premiums. To apply for extra help, you should visit or call your local Social Security Administration office or apply on line at http://www.ssa.gov/prescriptionhelp

Provider Questions

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  1. Do I have to write new prescriptions for my patients?

    This depends on the plan. If your patient has to change pharmacies, a new prescription may be required. You may also have to write a new prescription if your patient's current medication is not on their plan's formulary and you prescribe an alternate, medically appropriate drug covered by the plan.

  2. Does Medicaid cover any drugs for people in a Medicare prescription drug plan?

    The NYS Medicaid program covers certain drugs that are excluded from the Medicare Part D plan coverage. These include barbiturates, when used for medical indications other than epilepsy, cancer, or a chronic mental health disorder, some prescription vitamins, and certain over the counter medications covered under Medicaid. For a list of over-the-counter drugs that are covered please visit https://www.emedny.org/info/fullform.pdf and look for "Rx Type 07" towards the end of the document.

  3. How is billing for Medicare Part B drugs or drugs that are administered in my office affected by the Medicare prescription drug program?

    Rules for Medicare Part B billing for drugs administered in your office have not changed and Medicare Part B remains the primary payor for covered drugs. Drugs that are covered under Medicare Part B will continue to be covered under Medicare Part B. Providers should continue to bill Part B as they have in the past, consistent with Medicare billing instructions.

  4. What information should I include on prescriptions I write for drugs covered under Medicare Part B?

    In order to simplify access to the Part D drug benefit in the outpatient setting, CMS recommends that prescribers include in the written prescription both the diagnosis and the indication as well as the statement of status as "Part B" for specific indications or "Part D" for all other indications.

  5. Where can my patient go for more information?

    They can call Medicare at 1-800-MEDICARE (1-800-633-4227) or access their website at http://www.medicare.gov. For the Medicare Prescription Drug Plan Finder or the Medicare Formulary Finder, they can go to https://www.medicare.gov/find-a-plan/questions/home.aspx. They can contact the New York State Health Insurance Information Counseling Assistance Program (HIICAP) at 1-800-701-0501 for individual assistance in understanding and choosing their plan. They can also contact their plan for more specific plan information.

  6. My patient has been stabilized on a drug that is not on the plan's formulary that they joined. Can my patient still get the drug while I evaluate other options?

    If a patient is new to a plan, Medicare Part D plans are required to have an appropriate transition process when the patient has been stabilized on a medication at the time they join the plan. This transition process differs from plan to plan and you, or the patient's pharmacist, may have to contact the plan for additional information. Plans must also provide coverage for all, or substantially all, drugs in the following drug categories: antidepressants, anti-psychotics, anticonvulsants, HIV/AIDS drugs, immunosuppressants, and antineoplastics. Plans must cover at least a 30 day transition supply of medication during the first 90 days of the beneficiary's enrollment. In the long term care setting, plans must cover at least a 31 day supply plus all necessary refills throughout the first 90 days of enrollment.

  7. What needs to be done if a medically necessary drug is not on a plan's formulary or requires prior authorization? Is there an exception or appeal process?

    The prescriber always has a choice to change the prescription to another medically appropriate medication that is covered by the PDP. However, drug plans must provide an exception/appeal process for drugs not on their formulary. To file an exception or appeal, contact the enrollee's plan. If a beneficiary has a prescription for a drug that requires prior authorization, the plan must also be contacted. Exception request forms can be found on CMS's web site at http://www.cms.hhs.gov/MLNProducts/Downloads/Form_Exceptions_final.pdf

  8. How long does it take for a plan to make a decision on my exception request?

    An expedited exception requires the plan to make a decision within 24 hours or less, dependent on the patient's medical condition. Only the prescriber can request an expedited exception. If an expedited exception is not requested, the plan has 72 hours to make a determination.

  9. Who notifies the provider and enrollee about the requirements of the Part D plan's appeal process and the outcomes of any reconsiderations or exceptions?

    A plan must provide their enrollees with information regarding their specific exception and appeals process. It is likely that you, or your patient, will need to contact the plan to find out the specific requirements and forms in order to submit an exception request. Pharmacies are also required to provide general written information on how a enrollee can request an exception and appeal.

    In general, the plan is responsible for notifying the provider and enrollee of the outcomes of exception and appeal requests. All negative decisions must be provided in writing to the enrollee.

  10. What if a Medicare Part D plan denies a prior authorization or an exception request?

    A person can appeal a drug plan's unfavorable exception or prior authorization decision. The first level appeal is made to the plan, generally done in writing by the enrollee or an appointed representative. Expedited appeals take only a few days. Plans must provide this information to beneficiaries upon enrollment. CMS describes this process in the "Physician Part D Resource Fact Sheet", which explains the exception and appeal process and provides a glossary of terms to help enrollees, providers and pharmacists better understand this process. This fact sheet can also be found on the CMS website at: http://www.cms.hhs.gov/MLNProducts/downloads/Part_D_Resource_Fact_sheet_revised.pdf

  11. Can Medicaid cover my patient's drug if the exception request was denied by my patient's plan?

    No. Only drugs that are excluded by law from being covered under the Part D plans, such as barbiturates when used for medical indications other than epilepsy, cancer, or a chronic mental health disorder, some prescription vitamins and some over the counter drugs, will still be covered under Medicaid.

Enrollee Questions

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  1. How much money will the Medicare prescription drug program cost me?

    Individuals with Medicaid and Medicare will have:

    No premium if enrolled in a plan designated by Medicare as no cost to persons with the full low income subsidy, or benchmark, and who are covered by both New York State Medicaid and Medicare.

    No deductible

    In 2011, there is a co-payment of $1.10 for generic and $3.30 for brand name (no co-payments for institutionalized long term care residents).

  2. How do I know what plan I'm in?

    Contact Medicare at 1-800-MEDICARE, refer to the CMS Plan Finder at https://www.medicare.gov/find-a-plan/questions/home.aspx or refer to the auto assignment letter sent to you by CMS in November for enrollment information. Information from your Medicare card will be necessary. This includes: name, DOB, effective dates of Medicare Part A & B and the beneficiary's Medicare ID number.

  3. Will my drug plan cover all of my medications?

    All medically necessary prescription drugs should be covered under your Part D plan. Your plan may require that you work with your physician to obtain a coverage determination or an exception to have some prescriptions covered. Drugs that are excluded by law from being covered under the Part D plans, such as barbiturates, when used for medical indications other than epilepsy, cancer, or a chronic mental health disorder, some prescription vitamins and some over the counter drugs, will still be covered under Medicaid.

  4. What drugs are included as "barbiturates"?

    Barbiturates include drugs like Phenobarbital and mephobarbital (Mebaral).

    For NYS Medicaid, prescriptions for a brand-name drug with an "A-rated"generic equivalent will still require prior authorization.

  5. How do I know if my drugs are covered?

    Each plan has their own formulary or drug list. You should get a copy of the formulary from your plan. This information may also be available in the information packet sent to you by your plan. You should discuss your current medications with your doctor when you receive this information.

  6. How do I compare formularies from different plans?

    Make a list of all your current medications, including name, dose size (for example - 2 pills, 300 mg in each pill) and dosage frequency (for example - 2 times a day). You can use this information to compare the list of drugs (also called a formulary) that are covered under each plan. You can compare formularies and plans by using the Medicare plan or formulary finder at http://www.medicare.gov or by calling 1-800- MEDICARE (1-800-633-4227).

  7. What if I don't want to stay with my current Medicare Prescription Drug Plan?

    Enrollees with both Medicaid and Medicare can change plans at any time. You can obtain assistance in finding a plan to better match your needs by calling 1-800-MEDICARE (1-800-633-4227) or by going to the CMS website at https://www.medicare.gov/find-a-plan/questions/home.aspx or by contacting HIICAP at 1-800-701-0501. However, you need to be enrolled, except for very special circumstances, in a Medicare prescription drug plan to keep your Medicaid benefits.

  8. Can my physician or my pharmacist enroll me in a different prescription plan if there is a better choice?

    Only you or your legally authorized representative can actually enroll you in a PDP or make enrollment changes. However, anyone, especially your physician or pharmacist, can help you understand your prescription drug plan.

  9. What is a legally authorized representative?

    A legally authorized representative is a term used by Medicare to identify who can legally act on your behalf in choosing and enrolling you in a plan.

  10. Can I use my Medicaid card to get my drugs?

    No, except under limited circumstances. Medicaid will continue to pay for barbiturates, when used for medical indications other than epilepsy, cancer, or a chronic mental health disorder, some prescription vitamins, and some over the counter drugs.

  11. Will I get a Medicare drug card?

    Yes. You must use your Medicare Part D plan card to obtain your drugs. If you haven't received your card, you can use the letter from your plan that states you are enrolled in their plan until you receive your new card. Your pharmacist may also be able to get the necessary information in order to bill your Part D plan from Medicare.

  12. I am getting a lot of information from Medicare and Medicaid about my drugs. Do I need to keep it?

    Yes, keep all of this information in a safe place. If you don't understand this information, take it to someone you trust that can help explain it. You can also contact Medicare at 1-800-MEDICARE or call a HIICAP counselor at 1-800-701-0501 for help.

  13. What if I can't afford the Medicare prescription drug program premium?

    Don't worry. Enrollees with both Medicaid and Medicare do not have to pay the Medicare prescription drug plan premium as long as they are in a "benchmark" plan. You are in a benchmark plan if you received a letter from Medicare (CMS) stating your plan assignment. You can also ask the plan if they are a "benchmark plan". If you choose a plan that is not a benchmark plan, you may have to pay a portion of the plan premium.

  14. Do I have to pay my Medicare co-pay?

    Yes, dual eligibles must pay a nominal Medicare co-payment for each prescription filled. In 2011 there is a copayment of $1.10 for generic and $3.30 for brand name drugs. Enrollees with both Medicaid and Medicare institutionalized in long term care facilities (more than one month) have no copayments.

  15. Will Medicaid pay my Medicare prescription co-payments?

    No. Medicaid cannot pay your co-payment for you. However, if you live in a nursing home, ICF-MR, or a residential psychiatric treatment center, you do not have to pay co-payments.

  16. Can prescription costs paid by EPIC be used to meet a spend-down requirement?

    Yes. Prescription costs paid by the EPIC program on behalf of an individual can continue to be used to meet a spend-down obligation.

  17. What can I do when my drug is not on my plan's formulary?

    Each plan must provide an exception process and appeal procedures. You will need your doctor or other provider to contact your plan and provide information about your medical condition. The plan will then make a decision if you can have an exception. If the exception is denied, you can then appeal that decision.

  18. What is an appointed representative?

    An appointed representative is defined by Medicare as someone who can act on your behalf to request an exception or appeal. While this can be your pharmacist or a family member/friend, we strongly encourage your doctor to act in this role and request the exception, if needed.

  19. Does the appointed representative have to document that the enrollee requested that they act on their behalf?

    While it is not required, the appointed representative may want to document that the enrollee has requested them to act on their behalf.

  20. How do I request a non-formulary drug?

    You, or your doctor, must submit an oral or written statement. If you start the request, your doctor must also submit a statement that says the prescription drug requested is medically necessary to treat your disease or medical condition. The plan would need to know what other drugs you've tried, how they worked, and how this one is working.

  21. Can I request a higher quantity?

    Yes. You, or your doctor, may also request an exception be made to allow you to get more pills/a higher dose per month.

  22. How long will it take for a decision?

    The plan must let you know if the drug is covered or there is a change in your quantity of pills/month within 72 hours. If your doctor believes there is a risk waiting for 72 hours, the plan must let you know in 24 hours or sooner if your health requires you have the medication sooner.

  23. If my plan agrees to cover my drug, do I have to repeat this process every time I get a refill?

    No, once they approve your drug or the quantity of pills you get each month, you should continue to get the drug for the rest of the enrollment year.

  24. What if my drug isn't covered?

    Contact your physician or ask your pharmacist what you should do next. Your physician may change your drug to a drug that is covered under your plan. If your physician wants you to stay on your drug, your drug plan must have a process for you to get drugs not on their formulary. You and your doctor can ask for an exception.

  25. If my plan denies my medications, will they notify me in writing?

    Yes.

  26. How do I know if my pharmacy is in my plan's network?

    You can call your pharmacy and ask if they are in your plan's network. You can also review the list of participating network pharmacies by checking with your plan or by contacting Medicare.

  27. Where can I go for more information?

    You can call Medicare at 1-800-MEDICARE (1-800-633-4227) or access their website at http://www.medicare.gov For the Medicare Prescription Drug Plan Finder or the Medicare Formulary Finder, you can go tohttps://www.medicare.gov/find-a-plan/questions/home.aspx You can also contact the New York State Health Insurance Information Counseling Assistance Program (HIICAP) at 1-800-701-0501 for individual assistance in understanding and choosing their plan. You can also call your prescription drug plan for more information.

Pharmacist Questions

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  1. Will Medicaid continue to cover any drugs for people in a Medicare Part D plan?

    The NYS Medicaid program will continue to cover certain drugs that are excluded from the Medicare Part D coverage. These include barbiturates when used for medical indications other than epilepsy, cancer, or a chronic mental health disorder, some prescription vitamins, and certain over the counter medications currently covered under Medicaid. Pharmacists can bill Medicaid for these drugs as they have in the past.

  2. How can I tell that a claim has been denied because the enrollee is a dual eligible (eligible for both Medicaid and Medicare) and their prescription should be billed to the Medicare prescription drug plan?

    If a claim is submitted to Medicaid for a dual eligible enrolled in a Medicare Part D plan, a message will be transmitted indicating that "enrollee has Medicare Part D". The drug claim should be submitted to the PDP for payment.

  3. Will duals have to meet deductibles and pay co-payments?

    Dual eligible Medicaid enrollees have no deductibles. However, they are required to pay a nominal co-payment for each prescription. In 2011, there is a copayment of $1.10 for generic and $3.30 for brand name or specialty drugs.

    Duals in long term care facilities (more than one month) are not subject to co-payments.

  4. Can Medicaid be billed for the Medicare Part D co-payments?

    No. The Medicaid program does not have authority to pay for Medicare pharmacy co-payments. The pharmacy may, on an individual and unadvertised basis, waive the co-payment. Pharmacies should be aware of any contractual issues with a plan prior to the waiving of co-payments.

  5. What if a enrollee does not have a Medicare prescription drug card or does not know what plan they are in?

    The pharmacist can refer to the enrollment letter sent to the beneficiary by CMS. They can also contact Medicare at 1-800-MEDICARE or refer to the CMS Plan Finder (information from the enrollee's Medicare Part A/B Health Insurance card will be necessary to complete this). The pharmacist should also be able to check the enrollee's enrollment status through their claims processing system by doing an eligibility inquiry (E-1 transaction).

  6. Will Medicaid pay for a drug if the Part D plan doesn't?

    No. Only drugs that are excluded by law from being covered under the Part D plans, such as barbiturates when used for medical indications other than epilepsy, cancer, or a chronic mental health disorder, some prescription vitamins and some over the counter drugs, will still be covered under Medicaid.

  7. Are drugs still under Part B?

    Yes. Drugs that are covered under Medicare Part B continue to be covered under Medicare Part B. Part B should be billed before Part D. Providers should utilize Part B as the primary payor, consistent with Medicare Part B billing instructions. In order to simplify access to the Part D drug benefit in the outpatient setting, CMS recommends that prescribers include in the written prescription both the diagnosis and the indication as well as the statement of status as "Part B" for specific indications (see the indications at https://www.cms.gov/pharmacy/downloads/partsbdcoverageissues.pdf ) or "Part D" for all other indications.

  8. Does Medicaid continue to cover co-payments and deductibles for drugs covered under Part B?

    Yes. Consult the Medicaid Update and Pharmacy Provider Manual for the billing policy and instructions. Providers may not bill dual eligible enrollees for Part B co-payments.

  9. Will the pharmacist receive any information regarding formulary requirements from a plan such as step therapy, quantity limits, or prior authorization requirements, when they submit a claim?

    Yes. Pharmacists are encouraged to pay attention to any special messaging they may receive through the claims processing system. Some of these messages may include information regarding the need for prior authorization or the need to take action (calling a plan's hotline to ensure the processing of a transition supply of drug).

  10. Who do I bill for supplies?

    Insulin-related supplies defined as syringes and needles, gauze and swabs should be billed to the Part D plan. Other supplies covered by Medicare Part B can be billed to Medicare. Supplies not covered by Medicare can be billed to Medicaid.

  11. If a full dual presents a Medicare and Medicaid card and is not enrolled into a Part D plan, how do they obtain their prescriptions?

    Use the program Limited Newly Eligible Transition Program also known as LiNet, administered by Humana. Under the LiNet process new dual eligibles will be retroactively enrolled, on a temporary basis, into just one PDP with an open formulary, no prior authorization, and no network pharmacy restrictions. They will then be auto enrolled into a benchmark Part D plan.

Nursing Home Questions

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  1. How can I determine what Part D plan my residents are in or if they have been reassigned to a new plan by CMS?

    In addition to using the web-based Prescription Plan Finder tool at http://www.Medicare.gov for individual resident inquiries, nursing homes can contact Medicare at 1-800-Medicare.

  2. A nursing home's administrator or its designee may act as a resident's designated representative for Medicare Part D enrollment decisions. When should a nursing home take the step of enrolling a resident in a Medicare Part D plan?

    The nursing home should exhaust all efforts to identify an individual with an interest in the well-being of a resident, who can act as the resident's designated representative, before establishing the Administrator or its designee as such.

  3. If a nursing home provider enrolls a resident in a Medicare Part D plan, must the resident and his/her designated representative be notified of the enrollment?

    Yes. The plan in which the resident is enrolled, the date of enrollment, and other relevant information should be communicated to the resident and his/her designated representative upon enrollment. In addition, the resident and his/her designated representative should be notified that the resident has the right to change plans, within the rules established in the program. Nursing home residents may change plans monthly.

  4. Must the nursing home provider establish guardianship for the purposes of enrolling a resident in a Medicare Part D plan?

    No. More information on this topic can be found at http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter06-16.pdf

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