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Drug Coverage

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Starting in January 2006, Medicare Prescription Drug Coverage provides insurance coverage for prescription drugs.  It pays for both brand name and generic drugs; it offers a choice of plans to Medicare beneficiaries.  Health care professionals need to be aware of this benefit and how it impacts their patients. 

Patients with questions regarding the Medicare Prescription Drug Coverage should be referred to 1-800-Medicare and www.medicare.gov.

Educational Products for Health Care Professionals:

  • MLN Matters Drug Coverage Series:  Several articles are available (see Downloads section below) on a range of topics related to Medicare prescription drug coverage

Standard Forms & Tools:

  • Model Part D Exception and Prior Authorization Request Form - A standardized form that physicians can use to request an exception and coverage for non-formulary drugs (see Downloads section below)
  • Medicare Prescription Drug Coverage Provider-Pharmacist Communications Form  (for Prescribers) - The optional fax form in the downloads area below is a model template that can be adopted by plans to receive requests for prescription information or changes. CMS is not mandating the use of this fax form.

Medicare Prescription Drug Appeals & Grievances

CMS has a dedicated web page with information related to grievances, coverage determinations and exceptions, appeals under Part D, and other guidance (see link to the page in Related Links Inside CMS below).

Sources of Additional Information for Health Care Professionals

  • Part D Formulary Information for Physicians   This web page includes links to plan formularies, an optional fax form for requesting formulary exceptions, as well as a regional list of plan contacts for filing appeals and exceptions (See link in Related Links Within CMS section below)
  • State Health Insurance Assistance Programs (SHIPS) Beneficiaries may also contact their SHIP counselor for information on prescription drug coverage. To find the telephone number for the nearest SHIP, call 1-800-MEDICARE or visit www.medicare.gov/contacts/static/allStateContacts.asp.  (See link in Related Links Within CMS section below)
  • MMA Information Learn more details about the MMA legislation  (See link in Related Links Within CMS section below)
  • Download Formulary Software  Available through Epocrates, this software allows users to check a drug plan's formulary for drug availability and tier.  It is a free program viewable on a PDA or on a computer by physicians or their office staff.

 

Downloads
Drug Coverage Specific MLN Matters Articles - Series of 13 [PDF Zipped 2.1MB]

Model Part D Exception and Prior Authorization Request Form [PDF, 86KB]

Medicare Prescription Drug Coverage Provider-Pharmacist Communications Form [PDF, 23KB]
Related Links Inside CMS
MLN General Information

MLN Matters Articles

MLN Products

MLN Product Ordering

Web Based Training (WBT) Modules

Medicare Prescription Drug Appeals & Grievances

Part D Formulary Information for Physicians

State Health Insurance Assistance Programs (SHIPS)

Medicare Reform (MMA)

CMS Partnerships

Medicare.Gov/Publications/

Medicare.Gov/MedicareReform/
Related Links Outside CMSExternal Linking Policy

Download Formulary Software

Page Last Modified: 09/18/2007 9:22:57 AM
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