Medicare Part D help coming for pharmacists

November 21, 2005

There's some good news for pharmacists adrift in a sea of Medicare Part D confusion: They will be able to electronically determine whether a patient has prescription coverage, and they don't have to keep track of how much beneficiaries have spent out of pocket.

There's some good news for pharmacists adrift in a sea of Medicare Part D confusion: They will be able to electronically determine whether a patient has prescription coverage, and they don't have to keep track of how much beneficiaries have spent out of pocket.

By the time Part D goes live on Jan. 1, pharmacists will be able to send a real-time electronic query (E1) to find out whether a Medicare patient has drug coverage or to get information needed to bill a claim to a patient's insurance plan, said Tim Jones, R.Ph., VP of operations, Community CareRx, one of 10 national Medicare Rx plans. Such queries will go through the pharmacy's usual switch to NDCHealth, which the Centers for Medicare & Medicaid Services selected to be the facilitator to keep track of beneficiaries' eligibility and their true out-of-pocket (TrOOP) costs.

"CMS' thinking was that on Jan. 1, beneficiaries may or may not have a Part D card or they may have no idea about Part D at all," Jones told attendees at the recent annual meeting of the National Community Pharmacists Association in Fort Lauderdale, Fla. "CMS identified the need for a way for pharmacists to quickly identify the appropriate plans. They came up with the eligibility transaction, which serves the purpose well."

Pharmacists should ask their software vendors if they support the E1 transaction and whether a new agreement is needed to use the system, said Eidex, who added that NDC has established a standard agreement for all pharmacies and pharmacy software vendors.

NDC, not pharmacies, has to keep track of beneficiaries' TrOOP costs to determine when they become eligible for catastrophic coverage, said Eidex. The TrOOP level for 2006 is $3,600, but it can change from year to year. Beneficiary balances will not be provided to pharmacies. It's up to the Rx plans to answer questions about a beneficiary's TrOOP balance. The plans will send beneficiaries updates during months their balance changes. In addition, if there is a dispute about the balance, the beneficiary must either pay the pharmacy or decline the purchase.

While Medicare Part D is certainly complicated, the message for pharmacists is to avoid making a worst-case scenario and then trying to solve it, cautioned Jones. "It's best to step back and look at the basics," he said. "People are getting overwhelmed, and when they get overwhelmed, they shut down."

For more information about TrOOP on the Internet, go to http:// http://medifacd.ndchealth.com/, http:// questions.cms.hhs.gov/, or http://www.medicareresourcecenter.com/. You can also send an e-mail to troopquestions@ncdhealth.com
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