I.  MEDICAID EXTENSION -- for Dual Eligibles (people with both Medicare and Medicaid), there is a temporary reprieve because the New York State Medicaid program, like Medicaid programs in 27 other states, is TEMPORARILY allowing pharmacists to bill Medicaid in the event that the billing to the Part D plan doesn't go through for any reason.  This temporary relief was ordered by Gov. Pataki in a series of 7-day extensions.   This is described more below. 

2.  90-day TRANSITION SUPPLY FOR EVERYONE ONE MEDICARE PART D -- For ALL people on Part D, not just dual eligibles, Part D plans have been directed to provide refills of prescriptions for up to 90 days until March 31st.   This is for drugs that are NOT on the plan's formulary.  Normally, such drugs would be covered only the the member or their physician requested an EXCEPTION and it is approved.  During this 90 days, no exception should be required.  The memo to plans is attached which should help you make sure pharmacists bill the Part D plans. 

MORE ON the MEDICAID EXTENSION --  and please read below for a WARNING

1)    Temporary FULL Medicaid coverage for dual eligibles will end FEB. 15th, 2006.  Until then, pharmacists may bill Medicaid any time the Part D card doesn't work or the drug is not approved. 

2)    From Feb. 16 - March 8, 2006, Medicaid will still pay but ONLY if the pharmacist attempts to bill Medicare drug plan first, and  verifies that s/he did so following verification procedures set up by the federal Medicare agency, called CMS.  These procedures are on page 4 of the attached NYS Dept. of Health Medicaid Update, which is the official instructions to all health care providers who accept Medicaid.  For more information, go to: http://www.health.state.ny.us/health_care/medicaid/program/update/2006/feb2006.htm 

NOTE:  During this time the 90-day "transition" policy described above should help too -- pharmacists should bill the Part D plan and request the transition supply.  

3)    After March 8th -  Medicaid will pay only

        A)    for drugs EXCLUDED from the Part D program like over the counter drugs, ativan, valium and other "benzodiazapenes," barbiturates.  See list at http://onlineresources.wnylc.net/pb/docs/NYFAHC_Fact_Sheet.pdf 

        B)    If the Part D plan has denied coverage for a drug because it is not on its formulary, your doctor will have to request an EXCEPTION from the plan, documenting why the drug is medically necessary. The necessary form can be found at: http://www.medicarerights.org/exceptionrequest_template.doc  

If the exception is approved, then the Part D plan pays.  If the exception is denied, the doctor must call in for a "verification" number, write that number on the prescription, and then Medicaid will pay for it.  The procedure for doing this is in the December 05 Medicaid Update at http://www.health.state.ny.us/health_care/medicaid/program/update/2005/dec2005spec.htm