CASE FLASH: MEDICAID COVERAGE OF PART B MEDICINES

Ms. F is a New Yorker who has both Medicare and Medicaid. She takes Albuterol, a common asthma medication. It is covered by Medicare Part B (outpatient medical insurance) instead of Medicare Part D (prescription drug insurance). When she went to the pharmacy to pick up her prescription, her pharmacist told her that Medicaid cannot help pay for drugs covered by Medicare Part B, and that she would have to pay the 20 percent that Medicare does not cover. Ms. F could not afford it and so had to walk away without the medicine. Knowing that Medicaid had covered it before, Ms. F called her local State Health Insurance Assistance Program (SHIP) for help.

A SHIP counselor confirmed for Ms. F that Medicaid does cover a person’s out-of-pocket costs for Part B drugs as long as they are on Medicaid’s formulary. However, whether Medicaid covers out-of-pocket costs for Part D drugs varies from state to state. (Massachusetts dual eligibles should never pay more than $1 for a generic drug or $3 for a brand-name drug. The maximum co-payment a Part D Plan can charge a dual eligible is $5.35, in 2007, but the pharmacy would bill MassHealth as a secondary payor for the amount over $1 or $3.) The SHIP counselor then called Ms. F’s pharmacist and asked him to call the state’s Medicaid pharmacy benefits line (the number can be found by calling the local Medicaid office). Once the pharmacist realized that Medicaid will help to pay for Medicare Part B drugs, he billed both Medicare and Medicaid, and Ms. F was able to pick up her prescription without having to pay anything out of pocket.

Note: For an explanation of when Part B will cover your prescription drugs, see the Medicare Rights Center’s chart, “ Getting Medicare to Cover Your Drugs: Parts A, B, or D?”

-Adapted from: Medicare Watch, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 10, No. 6: March 20, 2007

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