OPS-11-11-01 - = Changes to Pharmacy Benefits for Adults Ages 21 and Older

Welcome to the OIM Web

OIM Home | = Category Search | = Global = Search |=20 Feedback=20

OA=20 Training Resources | OA=20 HRD Schedule | IMSTP = E-learning |=20

OIM Web = Desk=20 Guide |=20 PA600 Tip Sheet | SUA=20 Desk Guide | SSP= Check=20 Replacement Guide

DCA/QC | Employee Links = | Child Support = Co-Browsing |=20 DPW Office of Adminstration | = Job=20 Postings

=20

Deputy's = Corner/ CAO = Focus/ TANF R/ Customer Service = Center/Modern = Office/LIHEAP-eCIS= /Phase=20 IV-B/LEP

Operations Memorandum - Medicaid
OPS111101

	November=20 28, 2011
SUBJECT:	Changes=20 to Pharmacy Benefits for Adults Ages 21 and = Older
TO:	Executive Directors
FROM:	Richard=20 Wallace, Director, = Bureau of=20 Operations

Purpose

To inform = County=20 Assistance Offices (CAOs) that effective January 3, 2012, changes are = being made=20 to Medical Assistance (MA) pharmacy benefits for adults ages 21 and=20 older.

Background/Discussion

Based on = changes to=20 state law, the Department of Public Welfare (DPW) is making changes to = MA=20 pharmacy benefits for adults ages 21 and over in the Fee-for-Service = delivery=20 system. This includes = ACCESS=20 Plus.

The = changes do not apply to the=20 following:

Individuals under 21 years of=20 age;
Individuals living=20 in a Long Term Care or intermediate care facility;=20 or
Individuals who=20 are pregnant.

MA = physical health=20 Managed Care Organizations (MCOs) have the option to impose the same or = lesser=20 pharmacy limits for their members. =20 If the MA physical health MCOs impose the same or lesser limits, = they=20 will issue individual notices to their members to inform them of their = pharmacy=20 benefit changes.

Individuals will be=20 eligible for six prescription drugs each month.

This=20 change also applies to individuals who have prescriptions not covered by = Medicare Part D.

Individuals with=20 Medicare Part D must get prescription drugs through a Medicare Part D=20 Prescription Plan. MA = only covers=20 some prescriptions drugs that are not covered by Medicare Part D, such = as=20 barbiturates and benzodiazepines. DPW will = grant a=20 benefit limit exception to any of the pharmacy limits described in the = notice=20 when one of the following circumstances applies:

DPW=20 determines the individual has a serious chronic illness or other = serious=20 health condition and denial of the exception = will=20 jeopardize the life of the individual;
DPW=20 determines the individual has a serious chronic illness or other = serious=20 health condition and denial of the=20 exception will result in the rapid, serious deterioration of = the health=20 of the individual;
DPW=20 determines that granting a specific exception is a cost-effective = alternative=20 for the MA Program; or
DPW=20 determines that granting an exception is necessary in order to comply = with=20 Federal law.

The Office = of=20 Medical Assistance Programs (OMAP) developed a notice to explain the = changes and=20 benefit limit exception process. Notices will be centrally = printed and=20 mailed to the payment name of each household that has one or more adult = members=20 with Fee-for-Service pharmacy benefits. Mailing of these notices = started on=20 November 21, 2011.

A copy of = the notice=20 is included as an attachment= for = informational=20 purposes. OMAP is = developing a list=20 of Frequently Asked Questions which will be made available to the CAO=20 separately. CAO staff = should use=20 this information to assist any individual who may contact the CAO with = questions=20 about changes to pharmacy benefits.

MA = recipients may=20 also call the MA Recipient Service Center at 1-800-657-7925 with = questions about=20 the pharmacy benefit changes.

NEXT=20 STEPS

Share = this=20 information with appropriate staff.
Contact = your Area=20 Manager with any questions.
Changes = in=20 Pharmacy Benefits will be incorporated into the Medical Assistance = Eligibility=20 Handbook, Chapter 338, Appendix G.=20

OIM Web = Disclaimer=20 | Text Version = | Con= tact=20 Us =A9 2005 Commonwealth of PA - DPW

Welcome to the OIM Web

Operations Memorandum - MedicaidOPS111101

Operations Memorandum - Medicaid
OPS111101