The Centers for Medicare and Medicaid Services (CMS) have randomly auto-assigned duals to 15 different PDPs. If recipients do nothing, they will be automatically enrolled into the CMS assigned PDP on January 1, 2006. CMS letters, which were printed on yellow paper for easy identification, were mailed to recipients in November 2005. These letters advise recipients as to which plan they have been auto-assigned.

Recipients should be reminded to keep all their Medicare and Medicaid prescription drug information in one place. This information can be used to help the recipient, or others assisting the recipient, in understanding and maximizing their drug benefit.

The "auto-assigned" prescription drug plan may or may not be the best match for an individual, based on a recipient's drug needs and the pharmacies which they currently use. Recipients can change plans at any time and may obtain assistance in finding a plan to better match their needs by calling 1-800-MEDICARE (1-800-633-4227) or going to the CMS website at http://www.medicare.gov/mpdpf.

CMS has identified 15 PDPs in New York State as "benchmark" plans. Dual eligible recipients should be encouraged to join these plans. If they change their plan to another benchmark plan, they will not be responsible for any additional monthly premiums. If they choose to join any "non-benchmark" plans, they may be responsible for monthly premium payments.

Only the recipient or their legally authorized representative can actually enroll the recipient in a PDP. However, anyone can help the recipient choose a plan. The Medicare Prescription Drug Plan Finder at http://www.medicare.gov/mpdpf is the best way to find out what plans will meet a particular person's needs. You can also call 1-800-MEDICARE for information and assistance.

Whether a recipient chooses their own plan or remains in the plan that was assigned by CMS, they will receive a Medicare prescription drug card in the mail. They must use this card at the pharmacy to receive prescription drugs beginning January 1, 2006. In some cases, Medicare prescription drug cards may not be available from the plans by January 1, 2006. PDPs may issue letters to their enrollees that confirm the recipient's participation in their plan until the plan cards are issued. These letters should be taken by the recipient to the pharmacy when filling a prescription.

NYS Medicaid recipients are expected to fully maximize the benefits of the PDP plans. Recipients must utilize the PDP network pharmacies and formularies. If a drug is not covered by the plan, the exception and appeal process must be used to obtain coverage for the non-formulary drug. The prescriber may also change the prescription to a drug covered by the plan if medically appropriate.

The Medicare prescription drug benefit is provided through commercial prescription drug plans which include the following features:

Covered items under the Medicare Part D Drug Benefit include:

Plan formularies must include all, or substantially all, of the drugs in the following drug classes in 2006:

Each plan will have their own formulary which may include a variety of utilization management tools such as: prior authorization, step therapy, and/or quantity limitations. These formularies can change; however, plans are required to notify their enrollees who use an affected drug, at least 60 days prior to the change.

Plans must provide for an appropriate transition supply for new enrollees to access their prescribed drugs that are not on the enrollee's PDP formulary. Each plan has its own transition process and the supply of drugs provided to the enrollee during the transition process also varies among plans.

The recipient, their appointed representative, or the prescriber can request an exception or appeal. An exception is also called an initial coverage determination. It is the first time that the recipient or their prescriber goes back to the plan with medical justification to request that a drug be covered by the plan. We encourage prescribers to assume this role. The prescriber will need to decide whether another drug covered by the recipient's PDP can meet their patient's medical need. If so, a new prescription for the covered drug can be written and no additional action is needed. Otherwise, the prescriber will need to file an exception request or appeal request by contacting the recipient's plan. Be prepared to provide medical justification for your request.

If the exception is approved, the exception applies to the initial fill and refills. If the exception request results in a denial, PDPs are required to complete and issue a "Notice of Denial of Medicare Prescription Drug Coverage" to the recipient and their prescriber every time the plan denies an exception request/coverage determination. This form is labeled "Form No. CMS-10146" in the lower left hand corner. Please be sure to keep a copy of this denial notice in the patient's record.

The prescriber, the recipient, or their appointed representative is expected to continue the appeal process to get the recipient's drug covered by their plan when an exception is denied. The prescriber, recipient, or their appointed representative should contact the plan to determine how to proceed with the appeal process.

Dual eligible recipients will be required to pay a small co-payment ($1 for generics and $3 for brand and specialty drugs) even though a plan may have higher or tiered co-payments for their other members.

This means that a dual eligible will not be responsible for paying more than a maximum $3 co-payment each time the prescription is filled.

Duals in long term care facilities (nursing homes) are not subject to co-payments.

Dual eligibles will have no other out-of-pocket expenses.

Each plan has a preferred pharmacy network. Recipients should verify that the pharmacy they intend to use is in their PDP network to ensure that their prescriptions will be covered.

If an enrollee attempts to fill a prescription at a non-network pharmacy, they may need to pay the full price of the drug and be partially