For Pharmacists
MCPHS Pharmacy Outreach has created this resource page in an effort to provide pharmacists with timely and concise updates on Massachusetts insurance programs such as Prescription Advantage and MassHealth. If you have any questions regarding this information please contact MCPHS Pharmacy Outreach at 1-866-633-1617.
Prescription Advantage Update
Reductions to the current fiscal year budget for Prescription Advantage require that benefits be changed effective January 1, 2010. Prescription Advantage will no longer pay any part of the Medicare Part D plan premium for members in categories S1, S2 and S3. Members in these categories will be responsible for paying the premium invoices from their Medicare Part D plans to ensure that their Medicare Part D coverage continues. Co-payment assistance from Prescription Advantage is only available to members enrolled in a Medicare Part D drug plan or creditable coverage plan. Members will continue to receive coverage for benzodiazepines.
To ensure that Prescription Advantage will provide assistance at the appropriate point it is imperative that both the customer’s Medicare Drug Card and their Prescription Advantage Card are processed with each claim.
For further information about these changes please review the 2010 Prescription Advantage Rate Schedule and Fact Sheet . Please contact MCPHS Pharmacy Outreach at 1-866-633-1617 or Prescription Advantage at 1-800-243-4636 with any questions or concerns.
MassHealth and Medicare Part D
Limited Income NET Program
Effective January 1, 2010, Humana will begin administering the Limited Income NET Program for the Centers for Medicare & Medicaid Services (CMS). This program allows certain individuals with the Low Income Subsidy (LIS) to receive immediate need coverage at the point-of-sale if they are not already enrolled into a Part D plan. Additionally, CMS will temporarily enroll newly identified individuals with Medicare and Medicaid, (Dual-Eligibles) into the Limited Income NET Program contract (contract number X0001). This allows for a smoother transition as CMS autoenrolls them into standard Medicare prescription drug plans. Limited Income NET Program replaces the WellPoint Point-of-Sale Facilitated Enrollment (POS FE) process.
For claims assistance or more information go to the LI NET Pharmacy Portal or call 1-800-783-1307.
MassHealth Supplement Copayment
Individuals who are dually eligible(have both MassHealth and a Medicare drug benefit) should not pay more than the standard MassHealth copayment for their medications, $3.20 for brands, $1 or 2 for generics. Some dually eligible members are charged more than these copayments by their Medicare Part D plan.
If a Medicare prescription drug plan charges a dually eligible member a copayment (up to $6.00) that is higher than what the individual would have paid under MassHealth, charge the individual what she or he would have paid under MassHealth and submit a claim to MassHealth for the difference using other coverage code 2, 4, or 8.
In the event that the drug plan assesses a copayment in excess of $6 for a dual eligible member, pharmacy staff will need to contact the Part D plan in order for the plan to correct the copayment amount. Part D plans are required to accept “best available evidence” (BAE) as proof that an individual has Medicaid (MassHealth) and should therefore be charged the low-income-subsidy level copayments. Verbal confirmation may be sufficient for a plan to change the copayment levels for the member, other plans may request a copy of the MassHealth Card or a computer printout showing eligibility be faxed. If you experience a plan not accepting best available evidence please contact MCPHS Pharmacy Outreach for assistance.
If a Part D plan is unwilling or unable to correct the copayment amount at the time the prescription is filled, the MassHealth copayment denial can be overridden by placing a “99” in the submission clarification field (NCPDP field 420-DK). By using this override, the pharmacy is certifying that an attempt was made to contact and correct the copayment amount with the Part D plan. The use of these overrides will be closely monitored.
Note: Drugs excluded from the Medicare part D program (benzodiazepines, barbiturates, and certain OTCs) are a regular MassHealth benefit for dual elgible members. Bill MassHealth directly for these drugs and charge the usual MassHealth copayment.
For more information and updates about MassHealth billing please review Pharmacy Facts provided by MassHealth.