MEDICARE PART D

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 EqualityCare pays for benzodiazapines, barbiturates, calcium, iron, cough and cold medications and the same OTC’s that are covered for non-dual eligibles. For a complete listing of covered drug classes, please access the ACS Wyoming Medicaid website and click on the Billing Manuals left menu item and the Pharmacy Services Covered Services and Limitations Module.

PRODUCT COVERAGE

 Wyoming Medicaid covers all legend drugs that:

·              Have a signed rebate agreement in place

·              Are registered with Medispan

Wyoming Medicaid will not cover:

·              Agents used for weight loss, hair loss or fertility

·              Cosmetic agents, including Retin-A and Differin products for clients over the age of 21

·              Agents used for weight gain, including anabolic and androgenic steroids.

·              Some medications require prior authorization. Additional information may be found by clicking on the Preferred Drug List/Prior Authorization (PDL/PA) menu tab on the Office of Pharmacy Services home page.

CO-PAYMENT STRUCTURE

 The Wyoming Medicaid Pharmacy Program’s co-payment structure is as follows:

·          Generics (Multi-source medications) = $1.00

·          Brand-Name Medications = $3.00

Wyoming EqualityCare clients exempt from the co-payment requirement are:

·          Residents of a nursing facility or in swing beds

·          Pregnant clients

·          Clients under the age of 21

·          Family planning services

·          Emergency services

·          Hospice services