When Pharmacies Don’t Recognize Medicare Savings Plan Drug Pricing

Jun 14, 2024 | Economic Security & Outreach Blog, Medicare, Prescription Drugs

More Medicare-enrollees than ever are now eligible for the Medicare Savings Program (MSP), which covers the monthly $174.70 Medicare Part B premium, eliminates some co-payments for outpatient services, and provides a program called Extra Help that significantly lowers prescription drug prices.

But sometimes a pharmacist over-charges for drugs because the customer’s MSP enrollment status has not been updated in any of the systems they use in order to know what to charge.

How can we help clients in this situation?

Recently my fellow Hampshire County SHINE counselor Anna Viadero shared her process with untangling the pharmacy knot with a client who had paid more for a prescription than she ever had before. The pharmacist told her that none of her insurance cards were “working”: her Medicare card, MassHealth card, or her Medicare Advantage Plan card.

Anna called the MA College of Pharmacy and Health Sciences’ Pharmacy Outreach Program (1-866-633-1617). (This community program serves anyone.) The following was written by Anna in her email to the group:

Deb at the Pharmacy Outreach Program said they’ve been having a lot of trouble with people new to the Medicare Savings Program (MSP) going to pharmacies WITHIN 2-3 WEEKS of the date they were granted MSP and not getting Extra Help prices. She said the Social Security Administration and Medicare are not communicating in a timely manner. She said people can get reimbursed for meds for which they overpaid from the drug plan. They would need all or some of the info listed in the “Best Available Evidence” list, including receipts for the meds. She looked up a link for my client’s Medicare Advantage plan that details the reimbursement process and provided a fax number. She said the Pharmacy Outreach Program would help SHINE volunteers find reimbursement protocols on their clients’ drug plans.

She said this week I should call the Center for Medicare Services with my Unique ID first and check that my client’s Extra Help comes up on Medicare [becomes visible in their consumer database]. If it does, I should work with the client to get reimbursement from their Medicare Advantage Plan.

If Extra Help DOES NOT come up in Medicare, tell CMS her start date and tell them to fix it—then they may send you to Medicare ID Team (see below).

My client brought all necessary documents to the pharmacy–things considered “Best Available Evidence”–her new cards (including her MassHealth card) and Medicare card. She didn’t bring her notification letter, but I’m not sure if that would have helped if the pharmacist wasn’t finding Extra Help for her in the system.

There’s also the Medicare ID team that Deb said could help clients. They are at 1-800-462-1120 Option 3. You must have the client with you. You can also share the phone number with any client and they can call themselves. This would likely be for someone who tried to get meds, didn’t get Extra Help prices and didn’t pay full price for the meds–they could wait. Deb said calling this number lets Medicare do a workaround which will take 24-48 hours.

Here’s the list of “Best Available Evidence” (more detail on BAE is available on the CMS website):

• A copy of the member’s Medicaid card which includes the member’s name and an eligibility date during the discrepant period;
• A report of contact including the date a verification call was made to the State Medicaid Agency and the name, title and telephone number of the state staff person who verified the Medicaid status during the discrepant period;
• A copy of a state document that confirms active Medicaid status during the discrepant period;
• A print out from the State electronic enrollment file showing Medicaid status during the discrepant period;
• A screen print from the State’s Medicaid systems showing Medicaid status during the discrepant period; or
• Other documentation provided by the State showing Medicaid status during the discrepant period.