DIFFERENCES FROM MEDICAID PRESCRIPTION DRUG COVERAGE 

What are the key differences between Medicaid prescription drug coverage and the Medicare Prescription Drug Plans (PDPs)?

·        The private PDPs may have limited formularies or may place other restrictions on access to the medications a beneficiary needs.

·        Cost sharing likely will be higher (except for individuals who live in Intermediate Care Facilities for the Mentally Retarded (ICFs/MR).

·        Unlike Medicaid, there is no requirement to dispense an emergency supply of medications pending an appeal in a case where a plan seeks to deny coverage for a specific drug.

·        Unlike Medicaid, pharmacists are permitted to deny medications if beneficiaries are unable to pay the co-pays.

·        Current Medicaid rules limit these potentially harmful actions that can disrupt treatments and put the health of dual eligibles at-risk, but the Medicaid rules will not apply to dual eligibles when they transition to Medicare prescription drug coverage.