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NC Department of Health and Human Services
NC Division of
Medical Assistance

Medicare Part D


Pharmacy Information

Additional Information on Medicare Part D

Getting Ready for Medicare Part D 2010

Provided by Senior PharmAssist External Link & The NC Seniors’ Health Insurance Information Program (SHIIP)

As you know, we are in the open enrollment period for Medicare Part D until 12/31/09. There are 47 stand-alone Medicare-approved prescription drug plans (PDPs) available in North Carolina. In addition, many of the Medicare Advantage plans also include a drug benefit (MA-PDs), and their availability and cost varies by county. Many of the plans have changed their cost-sharing significantly (premiums, deductibles and co-payment or co-insurance amounts), changes what medicines they cover, and added more “utilization management tools” (PA, step therapy, and quantity limits). Some PDPs and MA-PDs that were available in 2009 are gone in 2010.

The E1 Transaction or Eligibility Inquiries

To determine a Medicare beneficiary’s Part D coverage information (any income or age): Your computer software vendor should have an online eligibility verification system. This allows you to enter basic information about a Medicare beneficiary to then find their drug plan data (BIN, PCN, etc.). However, pharmacies have different software and methods for conducting this search. Please speak to your management or software vendors to make sure your staff is ready to use this tool. Also, you can call the Medicare’s pharmacist helpline (1-866-835-7595) with the patient’s name, Medicare ID, DOB, and address – and they should give you the information you need to adjudicate claims.

POS Facilitated Enrollment

This process is designed to ensure that “dual eligibles” (individuals who have both Medicare and Medicaid) and others eligible for the Part D low-income subsidy or “extra help” can get their medications filled, even though their enrollment in a Part D plan is not active.

First, you should ask for a Part D ID card or plan letter with Limited Newly Eligible Transition (LI NET) enrollment data. If not available, conduct an E1 query or call the CMS pharmacy helpline to determine if s/he is already enrolled in a drug plan. If they are not already in a drug plan, and you understand they have both Medicare AND either Medicaid or the "low-income subsidy," then, effective January 1, 2010, you should use the new LI NET program administered by Humana (Argus as processor).

This replaces Wellpoint's Point of Sale Facilitated Enrollment (POS FE). It has an open formulary, no prior authorization or network restrictions. Instead of enrolling an individual into a "benchmark" plan to cover current and retroactive periods, CMS will automatically enroll the individual into the LI NET plan for this purpose. CMS will then prospectively enroll the individual into one of the "benchmark" plans ($0 permiums for the individuals with the full low-income subsidy). That enrollment should take place on the first day of the month after the LI NET enrollment but can take two months.

  • Humana's LI NET info:
    • BIN = 015599
    • PCN = 05440000
    • Cardholder ID = Beneficiary HICN
    • Patient ID = Medicaid ID or SS number
    • Group ID may be left blank
  • Details are available on Humana's Pharmacy Resource web page External Link
  • The LI NET provider help desk for this POS FE process is 1-800-783-1307
  • You should continue to perform an E1 query on the individuals who you help via the LI NET program on a monthly basis because they should be enrolled by CMS into a regular Part D plan within two month.
  • If you have questions about the POS FE claims submitted prior to January 1, 2010, call NextRx Pharmacy Benefits line at 1-800-957-5147

Transition Fill Policies

There is a 90-day time frame in which Part D plans should allow a 30-day temporary fill in outpatient settings if someone is in a new plan (or in some instances when someone is continuing in a plan, but the medication is no longer on formulary or has restrictions). This applies throughout the year and is most critical to remember at the start of each calendar year. This fill should count towards TrOOP (true out-of-pocket) and should be a negotiated rate.

Changing Plans and NCRx

“Dual eligible” Medicare beneficiaries, as well as anyone with “extra help” or the low-income subsidy, have a continuous “special enrollment period,” meaning they can join or switch drug plans at any time (effective the first of the following month). If someone with the full low-income subsidy is paying more than $2.50/generic or $6.30/brand for covered medications in 2010, then they likely need to switch plans or appeal for coverage. Any person who qualifies for his or her state’s SPAP (State Pharmacy Assistance Program) has one “special enrollment period” outside of the annual election period (11/15 – 12/31) to join or switch drug plans.

NCRx is NC’s SPAP for Medicare beneficiaries 65 and older, and the premium assistance will be up to $29/month for 2010. Call 1-888-488-6279 for more information as they do not contract with all Part D plans.

The NC Seniors’ Health Insurance Information Program (SHIIP) (1-800-443-9354), local SHIIP coordinators, Medicare (1-800-Medicare) and others – depending on your county – can help Medicare beneficiaries compare Part D plans using the CMS drug plan finder tool External Link.

Medicare Advantage Plans

In addition to the 47 stand-alone drug plans, there are dozens of Medicare Advantage plans, some of which also include drug benefits. Many Medicare beneficiaries are confused by these plans and how the benefits differ from traditional Medicare. Please refer these questions to NC SHIIP (1-800-443-9354) or your local SHIIP coordinators.

Late Enrollment Penalties

The late enrollment penalty for people who have not had “creditable” coverage since Medicare drug benefits began in 2006, though they were eligible, will not be reflected on the CMS/Medicare website. It is based on 1% per month of the 2010 national base premium ($31.94). As an example, if they were eligible for Part D in June 2006 (43 months from Jan. 2009), they will owe $13.41 per month more than had they signed up in June 2006.  People who are dual eligible or have qualified for the LIS program are not subject to the late enrollment penalty. Ready NC Connect NC