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Medicare Part D Prescription Drug Program 

On January 7, 2003 the United States Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This act amended Title XVIII of the Social Security Act. One of the provisions of this amendment was the creation of a voluntary program for prescription drug coverage under the Medicare program. This new Medicare benefit meant many individuals not covered for prescription drugs would be eligible for an affordable plan that covered prescription drugs. Those low-income Medicare clients receiving a drug benefit from a state Medicaid program were enrolled in a Medicare drug plan beginning January 1, 2006. These dual eligible beneficiaries still receive medical coverage or Medicare premium, co-payment, and co-insurance assistance from the state Medicaid program.

One of the major provisions of the Medicare Part D regulations is the federal government’s requirement that the state continue to pay for certain prescription drugs and over-the-counter (OTC) medications for dual eligibles that were covered by Medicaid but are not covered by the Part D programs. Wyoming Medicaid pays for benzodiazapines, barbiturates, calcium, iron, cough and cold medications and some of the OTC’s that are covered for non-dual eligibles.  

*Effective January 1, 2013 benzodiazepines and barbiturates will be covered by Medicare Part D and therefore, will not be covered by Wyoming Medicaid.  

Medicare Part D/Medicaid Dual Eligible Clients

If a client has coverage under one of the plans listed below then they are dual-eligible. There are only three (3) plans that a dual-eligible client would have coverage under. Drug coverage for current plans will remain the same.

Plan 290: Regular dual eligible clients (clients eligible for Medicaid and Medicare Part D drug coverage)

Plan 291: Nursing home dual eligible clients (clients eligible for Medicaid nursing home benefits and Medicare Part D)

Plan 293: LTC Waiver dual eligible clients (clients eligible for Medicaid LTC Waiver benefits and Medicare Part D)

Medicare Part D/Medicaid Dual Eligible Client Limitations

The Division of Healthcare Financing, Pharmacy Services covers only those drugs that are exempt from coverage by Medicare Part D prescription drug plans. These drugs include benzodiazepines, barbiturates, and Over-the-Counter (OTC) products currently covered by Wyoming Medicaid. Medicaid will not cover drugs that are excluded from a prescription drug plan’s formulary.

Pharmacies should bill Medicare eligible clients for benzodiazepines, barbiturates, and OTC products currently covered by Wyoming Medicaid in the same way they bill for non-dual Medicaid clients; through POS with the clients Medicaid identification number. Copays will still apply.

Nursing Home clients eligible for Medicare services may receive coverage of benzodiazepines and barbiturates through Medicaid. OTC medications are not covered for dual eligible nursing home clients because OTC medications are included in nursing home per diem rates.

Medicaid will not cover drugs that are excluded from a prescription drug plan’s formulary, so any issues concerning a dual eligible client’s drug coverage need to be directed to the client’s Medicare prescription drug plan.

The Wyoming Medicaid Pharmacy program will cost avoid Third Party Liablility (TPL) claims for Medicare Part D plans. According to CMS "the Medicaid program by law is intended to be the payer of last resort" and therefore, when claims are billed to a client who is eligible for both Medicare Part D and Medicaid, due diligence must be used to bill the claim to Medicare Part D first. For dual eligible clients, the Medicaid formulary is limited. For any questions regarding this policy, the GHS Pharmacy Help Desk can be contacted at 877-209-1264.

*Effective January 1, 2013 benzodiazepines and barbiturates will be covered by Medicare Part D and therefore, will not be covered by Wyoming Medicaid.