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West Virginia Income Maintenance Manual Chapter 28

West Virginia Income Maintenance Manual Page 3 Chapter 28 Special Pharmacy

28.3 APPLICATION/REDETERMINATION PROCESS The individual may apply at any time after receiving the transplanted organ. 28.3.1 APPLICATION FORM The Application for Special Pharmacy (DFA-SP-1) is completed by the Worker and forwarded to the Bureau for Medical Services (BMS) Medicaid Policy Unit for consideration. This is an interdepartmental form and is not given to (or completed by) the applicant. The form must contain the following information: • Applicant’s name, address, date of birth, Social Security number (SSN), sex, county of residence, case number, and race; • Individuals in the applicant’s home and the relationship of each to the applicant; • Gross income of the applicant, applicant’s spouse, and all dependent children living in the home; • Applicant’s Medicare eligibility status and participation in payment for drug costs. If eligible, provide the Medicare claim number and the beginning dates of Part A and Part B; • Applicant’s Qualified Medicare Beneficiary (QMB) eligibility status; • List of prescribed immunosuppressant/anti- rejection or antipsychotic drugs; • Average monthly cost to the applicant of the prescribed anti-rejection or antipsychotic drugs; • Name, address, and telephone number of the pharmacy; • Physician’s name; • Date of the transplant; • Date of the most recent Medicaid application and reason for denial; and, NOTE: Medicare pays 80% of the cost of anti- rejection drugs indefinitely, if all Medicare requirements are met. Medicare pays 80% of the cost of anti-rejection drugs for transplant recipients with End Stage Renal Disease (ESRD). When Medicare participates in the payment of the drugs, the Worker must deduct any amount Medicare pays and indicate only the amount for which the client is responsible. Only the remaining amount is used to determine eligibility and subsequent payment by the Department.