Scroll to the bottom of this page for additional links to helpful information.

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.)

For more information review the following:

Medi-Cal Web Site Resources

• 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)

Outside Resources

• 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.