Tips when dually eligible child (Medicare & Medicaid eligible) is denied medications

Earlier this morning, I spoke to a mother whose son is a dual eligible (receiving both Medicare and Medicaid), and he has been switched to a new Medicare Part D drug plan.  One of his prescriptions was denied last Friday because of Quantity Limits – the prescribing doctor wants him to take 5 of a certain anti-seizure pill per day, and the drug plan formulary has a limit of 4 pills per day.  This particular case had a happy ending!  The physician documented the necessity of  5 pills per day for this individual, and the drug plan approved it.
 
This is the information that you should know if a dual eligible is in a new Medicare drug plan and is denied his/her medication:
 
1)     For the first-time fill (usually 30 days) of prescription drugs (during the first 3 months of 2009), the Medicare drug plan must fill the prescription as written by the prescriber – even if the drug is not on the formulary or if there is a cost-containment requirement such as prior authorization (PA), step therapy (ST) or quantity limits (QL).  This requirement was put in place by the Centers for Medicare and Medicaid Services (CMS) to prevent a situation in which individuals are suddenly cut-off from the medication(s) that they have been taking.
 
2)     However, the transition requirement described above is only for the first-time fi ll;  therefore, if a consumer, staff, or family member receives notice that a particular drug will not be dispensed after the one-time fill (because it is not on the formulary or requires PA, ST, or QL approval), the physician or other prescriber needs to either (1) change the medication before the current prescription runs out, or (2) contact the drug plan to document the medical necessity of continuing the medication as originally prescribed.  A third option is to switch to another Medicare drug plan.
 
3)     The dual eligibles are not “locked-in,” and they can switch to another Medicare drug plan easily and without a penalty.
 
If a dual eligible wants to switch to another Medicare drug plan, help is available:
 
■        Free, personalized counseling about all aspects of Medicare – including Part D – is available from the State Health Insurance Assistance Program (SHIP): call
1-800-792-8820. There is a SHIP office in every county of New Jersey.
■        On the Internet - www.Medicare.gov -  a navigational tool is available to assist individuals to switch to another Medicare drug plan.
■      Call toll-free 1-800-MEDICARE
■        New Jersey’s Medicaid Hotline: 1-800-356-1561
■        Centers for Medicare and Medicaid Services, Region 2 Office in New York: 1-212-616-2222 (please note this is a toll call)
 

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