Beginning January 1, 2006, Medicare Part D, the new federal prescription drug benefit, will pay for prescription drugs for Medicare/Medi-Cal dual-eligible recipients and all other Part D-eligible recipients through private prescription drug plans. This change also applies to beneficiaries in Managed Care Plans.

Effective for dates of service on or after January 1, 2006, Medi-Cal will deny most claims for outpatient drug benefits for all Medicare Part D-eligible recipients. Six categories of drugs and supplies will continue to be covered by Medi-Cal, except in certain conditions. The six categories are listed below.

Providers supplying drugs to Medicare Part D-eligible recipients should submit claims with the Prescription Drug Plan (PDP) or Medicare Advantage-Prescription Drug (MAPD) Plan in which the recipient is enrolled. Recipients should have a MAPD or PDP card. Medi-Cal may be able to provide the recipient’s MAPD or PDP information when providers check recipient eligibility through their Benefits Identification Card (BIC).

Medi-Cal recipients who have met their monthly Share of Cost (SOC) are also eligible for Medicare Part D. If they have enrolled in the Part D program, those who have met their SOC in a single month can receive the low-income subsidy for the remainder of the year.

Dual-eligible individuals are automatically enrolled in a drug plan. If they do not like the plan selected for them, they may select a different plan. State and federal authorities have notified Medicare/Medi-Cal dual-eligible recipients of their eligibility and enrollment responsibilities. Medicare Part D-eligible recipients must make co-payments when they purchase drugs. Providers may choose to waive co-pays or may deny service if a recipient cannot pay the co-pay.

Even though there are nine categories of drugs excluded from coverage under Part D, drug plans have the option of covering drugs within those categories. Medi-Cal will continue to pay providers’ claims for the six “Part D excluded” categories of drugs that Medi-Cal currently covers. The categories that Medi-Cal will continue to cover are:

• Anorexia, weight loss or weight gain
• Symptomatic relief of coughs and colds
• Non-prescription drugs (Part D, not Medi-Cal, covers insulin and syringes)
• Barbiturates
• Benzodiazepines
• Prescription vitamins and minerals (Select single vitamins and minerals pursuant to prior authorization or utilization restrictions. Combination vitamin and mineral products are not a benefit. Vitamins or minerals used for dietary supplementation are not a benefit.)

• Emergency Drug Benefit Claim Submission To End June 29, 2007
• California Emergency Drug Benefit – January 2007 Updates (PDF format - 51 KB)
• California Emergency Drug Benefit – November 2006 Changes (updated November 3, 2006)
• California Emergency Drug Benefit – Instructions to Providers (updated January 5, 2007)
• Medi-Cal and MMA – Medicare Part D (Prescription Drug) Program (PDF format - 402 KB) –
       Presentation from the September 2005 Medi-Cal Now seminar
• Medi-Cal Notice of Action and Reduction of Benefits
• Medicare Part D Dual-Eligible Facilitated Enrollment FAQs (links to CMS instructions and payer sheet)
• Medicare Part D Prior Authorization and Exceptions Request Form
• Medicare Part D FAQs
• Medicare Part D Impact on Ancillary Costs
• Medicare Part D Included/Excluded Drugs – CMS Clarifications (PDF format - 46 KB)
• MMA Part D Carrier Cross-Reference Table Updated (PDF format - 14 KB)

• Center for Medicare & Medicaid Services Web site
• CMS Point-Of-Service (POS) Facilitated Enrollment Process in Four Steps for Pharmacists
• Medicare Part D POS Facilitated Enrollment Payer Sheet
• Medicare Prescription Drug Benefit Information – CDHS Web site
• Or call 1-800-MEDICARE.