Medicaid Drug Coverage: Who Can Answer My Question?

Aspect of Need Addressed: Medical, Financial

I cannot get a definite answer. Will all the medications that my psychiatrically disabled son needs be covered under the new Part D plan he now must enter, since his previous Part D provider has been disqualified by Medicare?

About a month ago, Medicare canceled its contract with the Part D prescription drug contractor, Fox Insurance, which was covering my disabled son's medications. All the medications he needs were on Fox's formulary, so there was no need for concern. Now that Fox is no longer qualified to participate in Medicare, my son must change his Part D prescription drug plan provider.

Working through the Medicare website, he has learned that there are seven so-called "benchmark" Part D plans for which he is eligible. These "benchmark" plans are for those like my son who are on disability and need "extra help" paying for their medication coverage. Those needing extra help, also called "dual eligibles", are eligible for both Medicare AND Medicaid. Medicare pays for 80% of all costs, after certain deductibles. For dual eligibles, NJ Medicaid pays for the 20% co-pays.

Now that he must change his Part D plan, there arises an important issue. None of the seven benchmark plans include on their formularies all the medications he is taking or needs for his various psychiatrically related ailments. This causes me as his father some concern. A mentally ill individual must have access to his medications! What is to be done?

For four weeks I have been trying to find answers. Visits to the NJ SHIP Counselors, experts in Medicare but not Medicaid, have not been fruitful. Calls to the NJ Medical Customer Call Centers, which take the calls for Medicaid, have not been clarifying, either. I'm still nervous that my son might lose access to some of his medications.

Here's where I think we are at the moment...

1. Medicaid is a back up insurance plan for Medicare. In my son's case, whatever Medicare does not pay, Medicaid will.

2. Drug formularies are set by the Medicare Part D drug plan providers in accordance with Medicare, not Medicaid rules. In other words, drug formularies are driven by Medicare. There is apparently no special Medicaid drug formulary.

3. Medicaid does, however, sometimes pay for medications that Medicare will not cover. Such is true for certain benzodiazepines. Although they are effective medications for certain types of anxiety, the "benzos" are problematic because they are also addictive and sometimes abused. Medicare does not cover them. But Medicaid sometimes does, as long as they are correctly prescribed and controlled.

Stay tuned...