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1133 Chapter 7:Worker guides • Section 6: MSP worker guides (07/2026) PDPs and MA-PDs are required to cover a list of prescription drugs called a formulary. Finding the right plan requires comparing plan formularies. You can use Medicare’s formulary finder at www.medicare.gov: to show if covered drugs are limited by “Formulary Tools”, such as Prior Authorizations (PAs) or Quantity Limits. There are also drugs that may be covered by Medicare Part A or B. Medicare Part A drugs are administered during a Medicare Part A hospital or Nursing Facility stay. Part B covers some drugs including those related to Medicare- covered transplants, some chemotherapy related drugs, and some drugs used in connection with Part B-covered durable medical equipment (such as drugs administered through a nebulizer). Medicaid covered drugs For full-dual eligible Medicaid individuals, who also have Medicare, the state will continue to provide coverage for one class of drugs: Limited over-the-counter medications (OTCs). Appeals and exceptions If a individual’s drug is not one of the drugs on the plan’s formulary, then the individual, the doctor, or the individual’s designated representative can contact the plan to ask for an exception. If a individual has been stable on a medication prior to enrolling into a plan, the plan must cover one 30-day supply within the first 90 days. This “transitionary supply” allows the individual and the doctor time to process any exceptions or appeals, or consider alternative medications. Exception timeframes • Standard: 72-hour turnaround, and • Expedited: 24-hour turnaround. If an exception is granted, then it remains in place for the calendar year. If the exception is denied, the individual can appeal that decision. Appeals follow the normal Medicare appeals process. • Redetermination by the plan; • Reconsideration by an independent company contracted with CMS; • Review by an administrative law judge; • Review by Medicare Appeals Council; • Review by Federal District Court. While Medicare Advantage plans can provide beneficial coordinated care for individuals, it is important to understand some of the payment parameters and requirements, before individuals enroll in the plans. There has been confusion regarding how individuals are able to access their QMB-only benefits through ODHS|OHA when receiving their Medicare A, B, and D benefits from a private Medicare Advantage Plan. ODHS|OHA does not pay the Medicare Advantage premium (if any), but will continue to pay for Part B and, if applicable, Part A premiums to the Centers for Medicare and Medicaid Services (CMS). ODHS|OHA pays for co-insurance and deductibles for Medicare covered medical services where a Medicare Advantage plan paid in lieu of Original Medicare, if the services are received from an ODHS|OHA enrolled provider, and within ODHS|OHA’s fee schedule. (OAR 461-135-0730(1)) ODHS|OHA will not pay copayments for Medicare