Fact Sheet: Transition from Medicaid to Medicare Pharmaceutical Coverage

Fact Sheet: Transition from Medicaid to Medicare Pharmaceutical Coverage

Once an individual is eligible for Medicare, he or she can no longer receive comprehensive drug coverage through Medicaid. That coverage must be provided by Medicare. There are some medications on the Medicaid formulary that are part of classes of drugs specifically excluded by law from Medicare coverage. These drugs are still covered by Medicaid at the state’s option and Illinois continues to cover these drugs. The two most common classes of drugs still covered by Medicaid are benzodiazepines and barbiturates.

The transition from Medicaid drug coverage to Medicare drug coverage should be seamless. The individual should be automatically placed into a Prescription Drug Plan if one is not chosen. The individual should have all the information necessary for the pharmacy to fill any prescriptions prior to the first day of Medicare coverage. And, the individual should have access to all medications at least once, even if it is not on the formulary, through one transition fill. Sometimes this does not happen.

Below are the three most common transition issues and how to properly address them so that access to needed medications is not delayed or denied:

Individual is denied access to a medication because it is not on the plan’s formulary.

Medicare Part D plans are required by the Centers for Medicare and Medicaid Services (CMS) to offer new members a one-time 30 day fill of a prescription that is not on the formulary any time within the first 90 days of coverage. The individual should ask for this and then consult with a physician to determine if another formulary drug can be used in the future or if switching plans will be necessary.

Individual’s co-payments are not consistent with those charged under the Low Income Subsidy (“Extra Help”) Program.

Here, the individual’s plan is failing to recognize that standard co-payments do not apply. Under the Best Available Evidence Rule, the individual must be allowed to submit evidence of Medicaid eligibility. Once submitted, the plan is required to recognize that the individual is a dual eligible and charge co-payments accordingly. Plans also have an obligation to assist the individual in securing proof of Medicaid eligibility if necessary. In order to utilize the Best Available Evidence rule, an individual should call the plan and request that this process be followed

Individual is not enrolled in a plan.

In some circumstances, an individual has not yet been assigned to a Medicare Part D plan. This is a catch 22. Medicaid won’t pay for the medication because the individual is eligible for Medicare. Medicare won’t pay for the medication because the individual has not been assigned to a plan. In this case, the pharmacy can enroll the person in the Limited Income Net Program (Li Net). This is a temporary Part D plan that covers all drugs that Medicare Part D could cover. Pharmacists who need assistance in effectuating this process can go to: