How does the PDP affect enrollees that are also eligible for Medicare (dual eligibles)?
Medicare Part D is the primary payor for dual eligible enrollees and should provide access to all medically appropriate medications through the coverage determination and appeal process. New York State Medicaid Program will continue to provide a “wrap-around” drug benefit for dual eligible enrollees. This benefit is limited to atypical anti-psychotics, antidepressants, anti-retrovirals used in the treatment of HIV/AIDS and anti-rejection drugs used in the treatment of tissue and organ transplants. The Medicaid wrap-around benefit may be used for the four drug classes listed above when: • These drugs are not initially covered by the Part D plan; • The patient does not meet the plan’s utilization management requirements; or • There are quantity limits inconsistent with the prescribed amounts.
