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COMAR 10.09.24.10

State of Maryland Medical Assistance Manual Revised July 2013 must be allowable deductions in the Medicaid post-eligibility calculation for the recipient’s cost of care contribution. They must, however, provide documentation of the out-of-pocket payments and a copy of the Disclosure of Creditable Coverage Notice from the employer or union retirement plan for the allowable deduction.

Non-Formulary Part D Drugs

PDPs and MA-PDs are required to develop transition plans for institutionalized individuals. Plans may allow for limited coverage of drugs that are not part of the plan’s formulary. Each PDP/MA-PD’s transition plan may vary. Plans must issue a periodic (at least monthly) statement to each beneficiary explaining all benefits paid and denied. Medicare Part D drugs that are not covered by the plan may not be covered by Medicaid and so, absent other drug coverage, would remain the individual’s responsibility. These charges may be allowable deductions in the Medicaid post-eligibility calculation for the cost of care contribution. Medicaid eligibility caseworkers should use the following rules to determine whether to deduct prescription charges as non-covered services: • When a plan denies coverage of a prescription, the beneficiary has the right to request an exception for coverage of the drug. The beneficiary is notified in writing of the plan’s decision on any exception requested. If the drug charge appears on the statement as a denial, and the beneficiary did not request an exception, do not allow the charge as a deduction for non-covered services.

• If the drug charge appears on the statement as a denial, and an exception was requested by the beneficiary but was denied, allow the charge as a deduction for non-covered services.

Institutionalized persons should be advised to maintain their statements and other related documentation needed for consideration of pharmacy expenses as non-covered services. This procedure will help ensure that legitimate costs for drugs not covered by the plan are correctly allowed in post-eligibility. By relying on the plans’ statements and exception notices, eligibility case workers do not need to know each plan’s formulary, or the non-formulary drugs covered under a transition plan or under the exception process.

Non-Part D Covered Drugs

Certain drugs are not covered under Medicaid Part D. State Medicaid programs have the option of covering these excluded drugs. Maryland Medicaid covers excluded drugs for Medicaid recipients, including institutionalized persons.

Questions regarding this issuance should be directed to the DHMH Division of Eligibility Services at 410-767-1463 or 1-800-492-5231 option 2 and request extension 1463.