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Ideas for Confirming and Understanding 2008 Enrollment
You can help your clients by:
- Receipt of 2008 Plan Membership Card: Make sure your clients have received a new membership card or letter confirming enrollment into their 2008 Part D plan. Both of these documents contain the data (called 4RX) needed by pharmacies to submit claims and fill prescriptions.
- Confirmation of Enrollment: Advise them to confirm their Part D plan enrollment for 2008. The Medicare Plan Finder personalized search and 1-800-MEDICARE will have 2008 enrollment information as of January 1. 2008. Pharmacists have access to this information now through an enhanced E-1 query.
- Counseling re-assigned Clients: Assist your re-assigned clients to research the cost, coverage and convenience of the plan to which they were re-assigned. Remember to counsel about the comparative pros and cons of accepting the re-assignment versus selecting a plan for which they might pay a small portion of the premium but have access to a more generous formulary. More information about counseling re-assigned clients is in the Extra Help section of MyMedicareCommunity.
Ideas for Helping When Your Clients Are At the Pharmacy
- Bring Proof of Plan: Emphasize to your clients the importance of bringing their 2008 membership card or enrollment confirmation with them to the pharmacy when they refill their prescriptions for the first time in 2008. This will make it easier for the pharmacy if the claims system doesn’t return an E-1 query with accurate enrollment or Extra Help status.
- Transition Fills: Have information ready for your clients and community pharmacies about transition fills. Remember plans are required to fill ongoing prescriptions the first time a new member goes to the pharmacy, even when the drugs aren't on the formulary, or are limited by utilization management requirements, then send an explanatory letter within 3 days of the fill. The transition requirements provisions of the Medicare Prescription Drug Manual are here. The pharmacy will also get a message through its electronic claims submission and can also give people a "heads-up" about the temporary nature of a Part D transition fill. Your clients should use the transition period to work with their treating physician to decide whether it’s ok to switch to a drug the plan covers with no limitations on access, or to request a formulary exception.
- Best Available Evidence: Tell your Extra Help clients how they can show the pharmacy proof of their Extra Help status so they can get their prescriptions by paying the Extra Help co-payments even if the E-1 query does not confirm that they have Extra Help. We discuss Best Available Evidence in the Library under Extra Help.
- Point-of-Sale Enrollment: If the pharmacy cannot identify the plan of an Extra Help beneficiary, be prepared to assist your clients and their pharmacies with information about the Point-of-Sale enrollment solution. CMS has released an updated guide to the point-of-sale solution for 2008, dated December 2007.
- Extra Help Grace Period: For your clients who were unredeemed, ask their plan if it adopted the three-month grace period during which the plan forebears on collecting premiums and cost sharing. Assess whether these clients should apply for Extra Help, or can re-gain Medicaid status through an income spend-down or Medicare Savings Program eligibility.
Ideas to Consider for Longer-Term Solutions:
- Medicare Advantage Open Enrollment Period: All of your clients who have Medicare Parts A and B can switch among Medicare Advantage plans or disenroll from Medicare Advantage to Original Medicare between January 1, 2008, and March. Remember that they cannot add or drop Part D.
- Extra Help Special Enrollment Period: Your Extra Help clients may switch plans as frequently as monthly. Such frequent switches are generally not advisable; if they are dissatisfied with their plan, changing to another one may be a strategy worth considering.
- Exceptions and Appeals: You can work with your clients and their physicians to request formulary exceptions to cover drugs the doctor believes your clients should continue to take even if they were removed from the formulary for 2008, were tiered up and are too expensive, or are newly subject to utilization management requirements such as prior approval, step therapy, or quantity limits.
