Medicare - Connecticut Pharmacists Association

Medicare

News & Issues > Hot Topics

This page updates Connecticut pharmacists on information they should know for the implementation of Medicare Part D.

This is a free service for all Connecticut pharmacists provided by the Connecticut Pharmacists Association.
If you are not yet a CPA member [Click Here] to join online!

Check back often for updated information on Medicare Part D!

Last updated: November 13, 2006

Most recent information:

Be Prepared for Medicare
Enrollment for Medicare Part D begins November 15th. While open enrollment continues until December 31st, CMS recommends that beneficiaries should be enrolled by December 8th to avoid delays. Here is what you need to know! The new benchmark premium for our region is $27.35. There are 18 PDPs that fall below the benchmark. For a list of MAPDs and PDPs for 2007 visit the Medicare page at www.medicare.gov.

Medicare Part D Drug Plan Workbooks Now Available
Pharmacists are now able to obtain copies of the new Medicare workbook for beneficiaries, entitled “Medicare Prescription Drug Plan Guide: How to Choose Your 2007 Plan.” The workbook - a collaborative effort of NACDS, NCPA, and America’s Health Insurance Plans (AHIP) --provides important information to help beneficiaries decide which type of Part D plan makes the most sense for them, given their current medication needs. [Click here to access the workbook].

We also encourage sharing this workbook with your patients and staff. Pharmacies are also able to “co-brand” the books by placing their logo on the back.

Facilitated Enrollment to Begin for Low Income Subsidy Medicare Patients
To ensure that beneficiaries receive the benefit of the extra help, CMS is facilitating the enrollment of certain beneficiaries into prescription drug plans. This week, CMS will begin mailing letters to approximately 1.2 million people with Medicare who have applied for and been approved for the extra help and those who are enrolled in other federal assistance programs such as Supplemental Security Income (SSI) and Medicare Savings Programs.

The letters let the beneficiary know in which Medicare prescription drug plan they will be enrolled if they take no action before April 30. Unless they enroll on their own during March, these beneficiaries will have their prescription drug coverage begin on May 1. CMS is enrolling these beneficiaries earlier to make sure that they receive the benefit of the extra help immediately, and without having to pay a penalty. These beneficiaries can still decline the enrollment before it becomes effective, and would not be charged a premium.

Attention Pharmacy Providers Servicing CT Medicaid, ConnPACE and CADAP Clients (a message from DSS:)
It has come to our attention that there are many pharmacy providers whose software can not accommodate the changes needed to bill Medicare Part D claims as originally outlined in Provider Bulletin 05-75 issued in December 2005. The major issue at this point is regarding the use of the “copay only” transaction for non-formulary Medicare Part D drugs. We are currently evaluating and testing the modifications necessary to allow for an ‘other coverage code of 3’ to be used on these claims. We hope to have this modification in by the end of day Friday March 10, 2006. Thank you for your cooperation while we make these changes to assure that clients have access to their medication.

DSS Edits Gone as of March 9th!
(a message from DSS:)
This is to inform providers that the claim edits for Medicare Part D that are currently in a "post and pay" status will be activated and set to deny as of March 9, 2006. These edits had been placed in a "post and pay" status in order for providers to make the necessary changes to their software to accommodate the new billing procedures and to allow for the new Medicare Part D program to address outstanding issues that affected client eligibility.

As of March 9, 2006, if a client is eligible for Medicare Part D Prescription Drug Plan (PDP) coverage and the drug is covered by Medicare Part D, the PDP must be billed prior to billing the claim to Connecticut Medicaid, ConnPACE or CADAP program. These claims must also be billed as "copay only" transactions in order for secondary billing to occur. Claims for non-formulary drugs will continue to be paid for through the copay only transaction. Claims will deny if they are not being billed correctly.

For additional information and billing procedures, please refer to Provider Bulletin 2005-75 or visit www.ctmedicalprogram.com.

Exceptions & Appeals Information
In the event the provider is seeking prior authorization or a formulary exception and the plan's routine protocol fails or the contacts are being made after normal business hours, then the exceptions number provided on CMS' website may be used. The Part D appeals number provided on CMS' website may be used to contact the plan for the purpose of appealing a determination. Go to http://www.cms.hhs.gov/prescriptiondrugcovgenin/04_formulary.asp to access these downloads.

Medicare Parts B/D Coverage Flashpoints
This table provides a quick and easy reference guide for the most frequent B/D coverage determination scenarios facing Part D plans and Part D pharmacy providers. It does not address all potential situations. For more extensive discussion, please refer to the Medicare Part B vs. Part D Coverage Issues document available at: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf
Click Here for the Coverage Flashpoints

Freqently Asked Questions
Formatted into "What if" questions, CMS has compiled a list of scenarios and solutions for pharmacies. You can download it in PDF format.
Click Here for CMS FAQ

PDP Transition Information for Connecticut
CMS has released transition information for each of the PDPs offered in Connecticut. You can download it in PDF format.
Click Here for the PDP Transition Info

Plan Finder
CMS has released their long-awaited plan finder. Enter patient specific information including zip code and list of drugs and it will match plans to your specifications. Check it out TODAY!
Plan Finder Click Here

Using WellPoint for Non-enrolled Dual-eligibles
CMS has issued a guide for using WellPoint to process those dual-eligible patients who "fell through the cracks" and are not enrolled in a Part D plan.
Click Here for the WellPoint Guide

For Your Reference:
Listed Alphabetically

CMS Website for Pharmacies:
http://www.cms.hhs.gov/Pharmacy/
This site has information for pharmacies who want to participate in the Medicare Part D prescription drug benefit.

Formulary Finder
CMS has also released their "formulary finder" tool on their website. The finder takes a list of drugs and matches them to plans in a patient's state. The only drawback is that is gives no plan details (premiums, co-pays, etc) to help patients make a decision.
http://plancompare.medicare.gov/formularyfinder/selectstate.asp

Medicare Rx Email Updates:
Please click on the link below and choose "PHARMACY_MMA-L" to sign up for the Medicare Rx Update emails
http://www.cms.hhs.gov/mailinglists/

National Provider Identifier
CMS has begun phasing in the National Provider Identifier in Fee-for-Service Medicare between now and May 23, 2007. Important dates for this phase in are as follows:

May 23, 2005 to January 2, 2006: Only existing Medicare numbers are to be used
January 3, 2006 to October 1, 2006: An existing Medicare number OR NPI with an existing Medicare number may be used
October 2, 2006 to May 22, 2007: An existing Medicare number OR NPI may be used
May 23, 2007: Only NPI numbers may be used

CMS is encouraging individual pharmacists to sign up for NPIs now to enable Medicare Part D MTMS reimbursement. For more information and to apply for an NPI number, go to: https://nppes.cms.hhs.gov.

National Counsel of State Pharmacy Association Executives (NCSPAE) Medicare Page
NCSPAE has compiled very useful information about the Part D benefit. A good supplement to this site.
http://www.ncspae.org/medicare/index.html

Home | Back to Top

		Medicare News & Issues > Hot Topics This page updates Connecticut pharmacists on information they should know for the implementation of Medicare Part D. This is a free service for all Connecticut pharmacists provided by the Connecticut Pharmacists Association. If you are not yet a CPA member [Click Here] to join online! Check back often for updated information on Medicare Part D! Last updated: November 13, 2006 Most recent information: Be Prepared for Medicare Enrollment for Medicare Part D begins November 15th. While open enrollment continues until December 31st, CMS recommends that beneficiaries should be enrolled by December 8th to avoid delays. Here is what you need to know! The new benchmark premium for our region is $27.35. There are 18 PDPs that fall below the benchmark. For a list of MAPDs and PDPs for 2007 visit the Medicare page at www.medicare.gov. Medicare Part D Drug Plan Workbooks Now Available Pharmacists are now able to obtain copies of the new Medicare workbook for beneficiaries, entitled “Medicare Prescription Drug Plan Guide: How to Choose Your 2007 Plan.” The workbook - a collaborative effort of NACDS, NCPA, and America’s Health Insurance Plans (AHIP) --provides important information to help beneficiaries decide which type of Part D plan makes the most sense for them, given their current medication needs. [Click here to access the workbook]. We also encourage sharing this workbook with your patients and staff. Pharmacies are also able to “co-brand” the books by placing their logo on the back. Facilitated Enrollment to Begin for Low Income Subsidy Medicare Patients To ensure that beneficiaries receive the benefit of the extra help, CMS is facilitating the enrollment of certain beneficiaries into prescription drug plans. This week, CMS will begin mailing letters to approximately 1.2 million people with Medicare who have applied for and been approved for the extra help and those who are enrolled in other federal assistance programs such as Supplemental Security Income (SSI) and Medicare Savings Programs. The letters let the beneficiary know in which Medicare prescription drug plan they will be enrolled if they take no action before April 30. Unless they enroll on their own during March, these beneficiaries will have their prescription drug coverage begin on May 1. CMS is enrolling these beneficiaries earlier to make sure that they receive the benefit of the extra help immediately, and without having to pay a penalty. These beneficiaries can still decline the enrollment before it becomes effective, and would not be charged a premium. Attention Pharmacy Providers Servicing CT Medicaid, ConnPACE and CADAP Clients (a message from DSS:) It has come to our attention that there are many pharmacy providers whose software can not accommodate the changes needed to bill Medicare Part D claims as originally outlined in Provider Bulletin 05-75 issued in December 2005. The major issue at this point is regarding the use of the “copay only” transaction for non-formulary Medicare Part D drugs. We are currently evaluating and testing the modifications necessary to allow for an ‘other coverage code of 3’ to be used on these claims. We hope to have this modification in by the end of day Friday March 10, 2006. Thank you for your cooperation while we make these changes to assure that clients have access to their medication. DSS Edits Gone as of March 9th! (a message from DSS:) This is to inform providers that the claim edits for Medicare Part D that are currently in a "post and pay" status will be activated and set to deny as of March 9, 2006. These edits had been placed in a "post and pay" status in order for providers to make the necessary changes to their software to accommodate the new billing procedures and to allow for the new Medicare Part D program to address outstanding issues that affected client eligibility. As of March 9, 2006, if a client is eligible for Medicare Part D Prescription Drug Plan (PDP) coverage and the drug is covered by Medicare Part D, the PDP must be billed prior to billing the claim to Connecticut Medicaid, ConnPACE or CADAP program. These claims must also be billed as "copay only" transactions in order for secondary billing to occur. Claims for non-formulary drugs will continue to be paid for through the copay only transaction. Claims will deny if they are not being billed correctly. For additional information and billing procedures, please refer to Provider Bulletin 2005-75 or visit www.ctmedicalprogram.com. Exceptions & Appeals Information In the event the provider is seeking prior authorization or a formulary exception and the plan's routine protocol fails or the contacts are being made after normal business hours, then the exceptions number provided on CMS' website may be used. The Part D appeals number provided on CMS' website may be used to contact the plan for the purpose of appealing a determination. Go to http://www.cms.hhs.gov/prescriptiondrugcovgenin/04_formulary.asp to access these downloads. Medicare Parts B/D Coverage Flashpoints This table provides a quick and easy reference guide for the most frequent B/D coverage determination scenarios facing Part D plans and Part D pharmacy providers. It does not address all potential situations. For more extensive discussion, please refer to the Medicare Part B vs. Part D Coverage Issues document available at: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf Click Here for the Coverage Flashpoints Freqently Asked Questions Formatted into "What if" questions, CMS has compiled a list of scenarios and solutions for pharmacies. You can download it in PDF format. Click Here for CMS FAQ PDP Transition Information for Connecticut CMS has released transition information for each of the PDPs offered in Connecticut. You can download it in PDF format. Click Here for the PDP Transition Info Plan Finder CMS has released their long-awaited plan finder. Enter patient specific information including zip code and list of drugs and it will match plans to your specifications. Check it out TODAY! Plan Finder Click Here Using WellPoint for Non-enrolled Dual-eligibles CMS has issued a guide for using WellPoint to process those dual-eligible patients who "fell through the cracks" and are not enrolled in a Part D plan. Click Here for the WellPoint Guide For Your Reference: Listed Alphabetically CMS Website for Pharmacies: http://www.cms.hhs.gov/Pharmacy/ This site has information for pharmacies who want to participate in the Medicare Part D prescription drug benefit. Formulary Finder CMS has also released their "formulary finder" tool on their website. The finder takes a list of drugs and matches them to plans in a patient's state. The only drawback is that is gives no plan details (premiums, co-pays, etc) to help patients make a decision. http://plancompare.medicare.gov/formularyfinder/selectstate.asp Medicare Rx Email Updates: Please click on the link below and choose "PHARMACY_MMA-L" to sign up for the Medicare Rx Update emails http://www.cms.hhs.gov/mailinglists/ National Provider Identifier CMS has begun phasing in the National Provider Identifier in Fee-for-Service Medicare between now and May 23, 2007. Important dates for this phase in are as follows: May 23, 2005 to January 2, 2006: Only existing Medicare numbers are to be used January 3, 2006 to October 1, 2006: An existing Medicare number OR NPI with an existing Medicare number may be used October 2, 2006 to May 22, 2007: An existing Medicare number OR NPI may be used May 23, 2007: Only NPI numbers may be used CMS is encouraging individual pharmacists to sign up for NPIs now to enable Medicare Part D MTMS reimbursement. For more information and to apply for an NPI number, go to: https://nppes.cms.hhs.gov. National Counsel of State Pharmacy Association Executives (NCSPAE) Medicare Page NCSPAE has compiled very useful information about the Part D benefit. A good supplement to this site. http://www.ncspae.org/medicare/index.html Home \| Back to Top	2009 National Pharmacist Workforce Survey Hot Topics Tobacco Cessation HFA Albuterol Inhalers Federal Limits on Pseudoephedrine Products Medicare Quality Diabetes Healthcare Medicare Parts B/D Coverage Flashpoints CMS Frequently Asked Questions Guide for Using WellPoint PDP Transition Info for CT Medicare Part D Survey Collaborative Practice Pilot Press Releases News Articles