E1 Transaction or Eligibility Inquiries
Your software vendor should have an online eligibility verification system to determine a Medicare beneficiary’s Part D coverage. Entering basic information into the system will direct you to the beneficiary’s drug plan data.
Call the Medicare Pharmacist Helpline with the patient’s name, Medicare ID, date of birth and address. The Helpline staff will provide information to adjudicate claims.
POS Facilitated Enrollment
This process ensures that dual eligible (individuals with Medicare and Medicaid) and others eligible for the Part D low-income subsidy can fill medications even though their Part D plan enrollment is not active.
- Ask for a Part D ID card or plan letter with Limited Newly Eligible Transition (LI NET) enrollment data.
- If LI NET enrollment data are not available, conduct an E1 query or call the Medicare Pharmacist Helpline.
- If the individual is not in a drug plan and has Medicare and Medicaid, or the low-income subsidy, then you use the new LI NET program administered by Humana (Argus as processor).
Transition Fill Policies
There is a 90-day period in which Part D plans should allow a 30-day temporary fill in outpatient settings. This applies throughout the year and is most crucial to remember at the start of each calendar year. This fill should count toward TrOOP (true out-of-pocket) and should be a negotiated rate.
Changing Plans and NCRx
Dual-eligible Medicare customers, and anyone with extra help or the low-income subsidy, have a continuous special enrollment period.