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MMA Frequently Asked Questions:
General Pharmacy

 

  1. What is MMA?

    MMA stands for the Medicare Prescription Drug Improvement and Modernization Act. This Act creates Medicare Part D, which provides a voluntary prescription drug benefit for all Medicare beneficiaries beginning January 1, 2006.

  2. How will this impact my patients and my pharmacy?

    Any patient who is Medicare eligible on January 1, 2006, or after, will be able to receive their medications through Medicare Part D. Currently, if a patient has both Medicare and Medicaid coverage, pharmacies will need to stop billing Medicaid for Part D covered drugs after December 31, 2005, and bill Medicare.

  3. What if my patients want to continue to receive prescription drug coverage through Medicaid and opt out of Medicare Part D? What will happen?

    Medicare Part D is a voluntary prescription drug program. However, if patients opt out of it, they will not have prescription drug coverage at all. Medicaid will NOT provide any drug coverage for Part D covered drugs.

  4. How will this new Part D prescription drug benefit be administered?

    The new drug benefit will be administered through private companies authorized by Medicare. The companies include:
    • Prescription Drug Plans (PDPs);
    • Medicare Advantage Plans (MA-PDs);
    • Special Needs Plans (SNPs), and
    • Some employer and union plans.

  5. What type of drug benefit does Medicare Part D provide?

    Medicare Part D requires all plans to provide at least a Standard Prescription Drug Plan, benefits can vary depending on the plan chosen:
    • Premium: estimated $37 per month;
    • Deductible: $250 deductible;
    • Coinsurance: patients pay 25% from $250-$2,250;
    • Coinsurance: patients pay 100% from $2,250-$5,100; and
    • Coinsurance: patients pay 5% above $5,100.

  6. What drugs does Medicare Part D cover?

    Medicare Part D covers:
    • Prescription drugs;
    • Biologicals (e.g. Procrit, Raptiva);
    • Vaccines (Hepatitis B for low risk individuals);
    • Smoking cessation drugs;
    • Compound drugs (2 or more drugs mixed together), and
    • Insulin (insulin injection supplies).

  7. What are the Medicare Part D exclusions?

    Part D exclusions include:
    • Agents when used for anorexia, weight loss, or weight gain;
    • Agents when used to promote fertility;
    • Agents when used for cosmetic purposes or hair growth;
    • Agents when used for the symptomatic relief of cough and colds;
    • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations;
    • Nonprescription drugs/Over-the-Counter (OTC) drugs;
    • Barbiturates (e.g. Barbital, Phenobarbital), and
    • Benzodiazepines (e.g. Klonopin, Valium, Xanax).

  8. Are the plans required to cover all drugs that are not excluded by law?

    The plans are required to cover a minimum of two drugs in every therapeutic category and/or class. The Centers for Medicare and Medicaid Services requires the plans to cover all, or substantially all, of the following drugs:
    • Anticonvulsants (seizure drugs);
    • Antidepressants;
    • Antineoplastics (cancer drugs);
    • Antipsychotics;
    • Antiretrovirals (HIV/AIDS drugs), and
    • Immunosuppressants (transplant drugs).

  9. What if my patient’s drug is not on the plan’s formulary?

    Medicare requires the plans to have an exception process so that patients can receive non-formulary medications, if medically necessary. Patients can also ask for a co-payment exception, which, if approved, patients will pay a lower co-payment.

  10. What options will my patient have if the exception request for a non-formulary drug is not approved?

    Plans may require the patient to try alternative drugs or meet other criteria before a non-formulary drug is covered, or risk no coverage for the specific non-formulary drug. Patients can also appeal the decision if the exception is denied.

  11. Many of my patients are seniors and people who have disabilities. They frequently use Barbiturates, Benzodiazepines, and over-the-counter (OTC) drugs. How will my patients gain access to these drugs?

    The Oregon Department of Human Services (DHS), Office of Medical Assistance Programs (OMAP) will continue to cover the following:
    • Drugs for anorexia, weight loss, or weight gain;
    • Prescription cough and cold drugs;
    • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations;
    • Nonprescription drugs/Over-the-Counter (OTC) drugs;
    • Barbiturates (e.g. Barbital, Phenobarbital), and
    • Benzodiazepines (e.g. Klonopin, Valium, Xanax).

  12. Some prescription drugs can be covered under Medicare Part B and Medicare Part D. How will I know whether to bill Medicare Part B or Part D?

    In general, if a prescription drug can be self-administered it would be billed to Part D. If a provider administers the drug, Part B is usually billed. However, in some cases, the patient’s diagnosis and/or the route of administration for the medication can determine if Part B or Part D is billed.

    Example: If parenteral nutritional supplements are being used for a non-functioning digestive tract, then they are considered a Medicare Part B drug. If the supplements are used for any other diagnosis besides a non-functioning digestive tract, then they are considered Medicare Part D drugs.

  13. Will dual eligibles have to pay co-payments under Medicare Part D?

    Yes, even those clients living at home or in adult foster homes, assisted livings, group homes, and other community based care (CBC) settings will pay co-payments. However, dual eligibles residing in institutions defined by Medicare as nursing facilities, intermediate care facilities for the mentally retarded (ICF/MRs), and psychiatric hospitals will not have to pay co-payments under Medicare Part D (these clients must reside in the institution for one full calendar month). DHS will NOT pay for Medicaid Part D covered drugs or co-payments.

  14. When will the plan information be available?

    Medicare has announce the plan names. Medicare also requires the plan to have the following information available in October 2005:
    • Formularies;
    • Pharmacy Networks, and
    • Transition Plans.

  15. My patients keep asking me questions about getting "extra help" or some kind of low-income subsidy (LIS) to pay for my drugs. What should I do?

    You or your patients must contact the Social Security Administration (SSA) at 1-800-772-1213 or DHS at 1-877-585-0007. SSA will determine LIS eligibility for patients.