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| Full Benefit and Partial Benefit Dual Eligibles |
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This section gives information for individuals who have both Medicare and Medicaid (known as full benefit dual eligibles) and individuals who have some of their Medicare costs covered through Medicaid, including Medicare Part B premiums, but do not have any Medicaid health benefits (known as partial benefit dual eligibles). Individuals with SSI only (and no Medicaid) are also included in this section. What are the Basics of the Benefit? If you are a partial benefit dual eligible (someone who has their Medicare Part B premiums and other Medicare cost-sharing amounts paid for by Medicaid, but does not have any Medicaid health benefits), you will be eligible to receive prescription drug coverage through Medicare as of January 1, 2006. What Will the Basic Plan Look Like?
If you are a full benefit dual eligible, this Fall you will be automatically enrolled in the lowest cost plan available in your area unless you choose to enroll in a different plan (for more information see the section “How Do I Sign Up For A Medicare Plan?”). Each plan will have its own listing of which drugs will be covered (known as a formulary). You must fill your prescriptions at a pharmacy that is in your plan network. Each plan will provide a list of pharmacies where you will be able to have your prescriptions filled. Once the drug benefit program begins on January 1, 2006, you are allowed to change plans up to once a month. If you are a partial benefit dual eligible, you can choose a plan by May 15, 2006, or Medicare will enroll you into a plan randomly chosen for you beginning June 1, 2006. You will also be allowed to switch plans up to once a month after January 1, 2006. Individuals with SSI only (no Medicaid) will only be able to switch
plans once a year, during open enrollment period. What Will the Benefit Cost Me?
If paying your co-pay is a financial hardship, you can ask your pharmacist whether they will waive the co-pay. However, unlike prescription drug coverage under the Medicaid program, pharmacists are not required to waive the co-pay and can refuse to fill your prescription if you cannot pay it. If you need help obtaining your medications because you cannot afford your co-pay, you may contact the following organizations for information about State Pharmacy Assistance Programs (SPAPs) or private manufacturer patient assistance programs:
If you do not have Internet access and need help getting phone numbers
for these organizations, call the NMHA Resource Center at 1-800-969-6642. How Do I Sign Up For A Medicare Prescription Drug Plan?
Plans may cover different drugs, so it is a good idea to look at all plans in your area before deciding to stay with the lowest cost plan or to sign up for another plan If a higher cost plan covers more of your medications than a lower cost plan, it may be worth the additional costs to avoid changing your medications or the need to go through a lengthy appeals process. A Plan Comparison Web Tool and Medicare Personal Plan Finder will be available at http://www.medicare.gov in late October 2005. These tools may help you in choosing a prescription drug plan that is right for your needs. For help evaluating your plan choices you may contact:
If you do not have Internet access and need help getting phone numbers
for these organizations, you can call the NMHA Resource Center at 1-800-969-6642. What Medications Will Be Covered by Plans?It is important to review the plans available in your area to see which drugs they will pay for since plans can choose to cover different medications. If you cannot afford a higher cost plan that covers all your medications, you should talk with your doctor to develop a safe plan to switch to another medication that your plan does cover or seek an exception. The Centers for Medicare and Medicaid Services (CMS) require that each plan cover at least two drugs in each drug category. They are strongly encouraging plans to cover a majority of medications in the following categories: anti-psychotics, anti-depressants, and anti-convulsants. Some drugs are not included in the new Medicare prescription drug benefit. These include: benzodiazepines (e.g. Ativan, Klonopin, Valium, Xanax), barbiturates, and drugs to treat eating disorders. If you take these medications, you should:
If you are a full benefit dual eligible and you are taking a medication that Medicare will not cover, you can contact your state Medicaid program (http://www.cms.gov/medicaid/statemap.asp) to find out if they will continue to pay for that specific medication. If you do not have Internet access and need help finding the phone number for your state Medicaid office, please call the NMHA Resource Center at 1-800-969-6642. Plans are allowed to make changes to their approved drug list at any
time. However, they must give 60 days notice of these changes to enrollees
who are taking that medication or provide enrollees with a 60-day supply
of the medication they are removing from the approved drug list. The
plan must also notify prescribing physicians and the Centers for Medicare
and Medicaid Services. What Do I Do If My Medication Isn’t Covered?If your plan does not cover your medication or your plan requires a higher co-payment for your medication than for other similar medications, you may seek an exception to your plan’s approved drug list (formulary). An exception is a formal decision by the plan to cover your medication or reduce your co-payment. If an exception is granted, it will last one year and will need to be requested again. To file an exception, first call the plan to find out whether they will cover your medication. If they say no, request that they send you that decision in writing and follow the steps in your plan documents to file an exception. Your doctor will have to give a statement in writing or by phone (depending on the plan’s process) to the plan that the medication you are seeking coverage for is medically necessary and that other similar medications on your drug plan or managed care plan’s list of covered drugs will not be effective or will be harmful to you. Plans are required to make decisions on exception requests within 72 hours or within 24 hours in emergency situations. If your exception request is denied, you may appeal that decision. Since this can take a long time, it is important to talk with your doctor about other medications that you can take while you are going through the appeals process. For more detailed information about appealing a plan’s decision, call the NMHA Resource Center at 1-800-969-6642 to request a copy of NMHA’s “Medicare Prescription Drug Coverage Getting Enrolled Consumer Workbook.” While your appeal is pending, or if you decide you do not want to
appeal, you may also contact a organization that helps consumers apply
for state or pharmaceutical industry-sponsored pharmacy assistance
programs that provide medications or cost-sharing assistance directly
to consumers: Partnership for Prescription Assistance http://www.pparx.org and 1-888-477-2669. You can also contact your local Mental Health Association
office http://www.nmha.org/affiliates/directory/index.cfm for information
about pharmacy assistance programs available in your state. Need Further Help Understanding Your Benefit?
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National Mental Health Association
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