For Professionals: Medicare billing, claims and appeals

Pharmacies Play Important Role in Beneficiaries’ Access to Part D Appeals

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Published: August 2006

Despite advocates’ efforts to educate beneficiaries and providers on the Part D appeals process, many people are still either unaware of these important appeal rights, or do not know how to access them. A main reason for this lack of knowledge is the absence of notification given to beneficiaries when they find out that their drugs are not covered, or are covered at a higher copayment amount than the beneficiary should pay. Many pharmacists actively work with beneficiaries’ prescribing physicians to help them find suitable covered drugs. Yet when this process doesn’t work and beneficiaries cannot get their needed drugs, pharmacists are supposed to either tell beneficiaries to contact their plans to find out why the drug(s) was denied, or post a general notice with this information. Advocates report that many pharmacists do not take this step. As a result, some beneficiaries either pay out-of-pocket for the denied drug, or in the case of people with low-incomes and/or who have limited English proficiency, go without their needed medicine. Some Health Insurance Counseling & Advocacy Program (HICAP) counselors have reported beneficiaries and/or family members taking on additional jobs just to cover their prescription drug expenses. Often times these drugs have been wrongly denied and if people were aware of the need to contact their plan and doctor and their right to appeal, many could get their drugs covered.

To help remedy this situation, numerous advocates are doing outreach to their local pharmacies and pharmacy associations and discussing ways to work together to help beneficiaries either obtain their medicines or begin the appeals process. Based on the Health Assistance Partnership’s (HAP) Pharma Gram, this notice provides clear, easy steps for beneficiaries to follow to start the appeals process if their medications are not covered. Advocates can photocopy and distribute the notice to their local pharmacies for posting and/or handing out to beneficiaries who come to pick up their medications.

Other advocacy efforts focus on encouraging and assisting pharmacists to use the new Emergency Drug Benefit (EDB). On May 16, 2006, as a result of the passage of AB 813, the EDB was established for individuals dually eligible for Medicare and Medi-Cal. AB 813 allows the California Department of Health Services (DHS) to continue covering the cost of medications for dual eligibles unable to access prescriptions from their private Medicare Part D plan in certain scenarios, and is effective from May 17, 2006 through January 31, 2007. This new program, however, incorporates major changes to the old program, both restricting the situations in which dual eligibles can access drugs through the state and making it more onerous for pharmacists to use when Medicare Part D does not work. Under the new program, pharmacies are required to submit a paper treatment authorization request (TAR) to Medi-Cal with an explanation of actions the pharmacy has taken in an attempt to receive payment through Medicare Part D. Advocates are concerned that the TAR requirement and other multiple steps required by the Medi-Cal Bulletin, issued May 16, 2006, may discourage pharmacists’ use of the EDB. DHS has already reported that the number of claims submitted to the state for emergency coverage has dropped significantly since these new restrictions have been put into place. Download a PDF of bulletin. (Note that DHS is in the process of revising this provider bulletin and should re-issue an updated version in August at www.medi-cal.ca.gov/default.asp).

Pharmacists who have questions about the EDB and working with Medicare Part D plans in general can call the California Pharmacist Association (CPhA) hotline at 877-PARTD-411. The hotline is available Monday through Friday from 8 a.m. to 6 p.m. Medi-Cal also has an eTAR option for submitting TARs online. See the Medi-Cal site for more information.

The more advocates know and communicate with pharmacists about the new Emergency Drug Benefit, the more they can be a resource to pharmacists attempting to put it to use. In addition, dual eligible beneficiaries may also begin asking their pharmacists about this benefit as DHS will be sending a special flyer describing the EDB to all newly dual eligibles who received a Reduction in Benefits Notice of Action (NOA) for loosing their Medi-Cal drug benefits. (As of early August, the exact date of this mailing has not yet been determined.) The EDB flyer will describe the new emergency program, and will be sent out in 12 languages. (Note that this is a one-time only mailing to duals who have already received a NOA. Those beneficiaries who become dually eligible in the future will receive the NOA but not the EDB notice.)

In returning to the issue of appeals access, the last edition’s article, Are People Missing the Boat?...Navigating Medicare Part D Appeals, mentioned that the Centers for Medicare and Medicaid Services (CMS) recommended but did not require Part D plans to accept their model “Coverage Determination Request Form.” On May 31st, however, CMS issued guidance clarifying that plans are now required “to accept any written instrument that is used by the enrollee, the enrollee’s appointed representative, or a prescribing physician to request a coverage determination,” including CMS’ model form. This change in policy will help beneficiaries access their Part D appeals rights and set the process in motion. (Note: The form is not to be used for non-Part D drugs or for biotech/specialty drugs for which drug-specific forms are provided.)

Ideally beneficiaries should be able to easily receive all their medications from their Medicare Part D plan. Yet, as that is not always the case, beneficiaries must know about their right to appeal, how to access that process, and where to go for help. Pharmacists play a key role in notifying beneficiaries of these rights, and also of helping dually eligible beneficiaries receive their needed medication through the new Emergency Drug Benefit. By communicating and working closely with local pharmacy networks, advocates can help pharmacies fill this important role help beneficiaries get the medications they need.

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