Medicare Part D Prescription Payments
TO: Medicaid Pharmacy Providers
FROM: Jerry Wells, Chief
Bureau of Pharmacy Services
Florida Medicaid
DATE: January 26, 2006
RE: Medicare Part D Prescription Payments
This is to announce that, after consultation with Governor Jeb Bush, Secretary Alan Levine has directed Florida Medicaid to immediately approve prescription payments on behalf of certain Medicare/Medicaid dual eligible recipients who are unable to obtain prescriptions or who are being required to pay deductibles, co-insurance or incorrect co-payments with their Part D prescription benefit.
To obtain Medicaid payment in these circumstances the pharmacy provider can obtain prior authorization by calling the ACS pharmacy help desk at (877) 553-7481. Medicaid payment will be authorized in the following situations, once attempts to bill a Part D plan or the Wellpoint 4 step POS system have been exhausted:
- Dual eligible individuals enrolled in a plan but whose Low Income Subsidy information did not post correctly resulting in requirements that they pay the $250 annual deductible, a 25% co-insurance and co-payments above the $1 generic and $3 brand limits. Pharmacies can bill Medicaid for Part D covered drugs for up to 30 days supplies and payment will be made:
- Up to $250 of the deductible
- The full 25% co-insurance
- Any co-payment above the $1 or $3 as appropriate
- Dual eligible individuals who should have been enrolled automatically but were omitted in error and who cannot be enrolled through the Wellpoint 4 step POS enrollment process. Pharmacies can bill Medicaid and payment will be made for Part D covered drugs for up to 30 day supplies.
Documentation to support the PA can be faxed to ACS at (877) 614-1078 using the Medicaid miscellaneous PA form as a cover sheet and should include:
- E-1 transaction screen prints returning no match;
- Wellpoint enrollment denial screen prints;
- Part D plan transactions reflecting deductibles, co-insurance or excessive co-payment requirements.
Denial of a covered drug as a 'non-formulary' or 2nd, 3rd or 4th tier drug must be handled through the individual plan or CMS/Medicare. The plans are obligated to pay for transition supplies. Beneficiaries are responsible for appropriate co-payments of $1 for generic drugs and $3 for branded drugs or for higher incomes, $2 generic and $5 for brand drugs in all cases.
Medicaid will continue to pay for Part D "Excludable drugs" as described in the December 11, 2005 notice to pharmacy providers.
If you have any questions, please feel free to contact the Medicaid Pharmacy Unit at (850) 487-4441 or email at PartDHelp@ahca.myflorida.com.
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