Last updated September 20, 2024
When to use:
When caller is unable to get medication and is requesting assistance.
Person does not have Medicare:
The Senior LinkAge Line receives state funding to provide help to Minnesotans of all ages with accessing the pharmaceutical manufacturers programs, also known as Patient Assistance Programs (PAPs).
If a person is unable to get their medications or cannot afford them and is not enrolled in Medicare, get the list of medications the person is taking. Determine if any of them are brand name drugs. Do a search for the manufacturer of the drug (usually the PAP apply only to brand name medications, and not generics). Check approved prescription drug sites quick reference for PAP information and other ways to potentially save money. Assist the person with getting the application(s) for the PAP so they can apply. Assist them with making an application if help is needed.
Person has Medicare:
If the person has Medicare and their plan will not cover their drugs, get the list of medications that are not covered and do a search to see if the manufacturer has a Patient Assistance Program (PAP) for people enrolled in Part D by visiting Medicare PAP Compare. Assist the person with getting the application(s) for the PAP so they can apply. Assist them with making an application if help is needed.
Information to collect from caller:
- Did the pharmacy tell the person why they are being denied?
- What is the rejection code the pharmacy received?
- i.e., Patient is Not Covered, Prior Authorization Required, Refill too soon, Filled After Coverage Terminated, Medicare Eligible -Client Must Enroll in Part D, Submit Bill To Other Processor Or Primary Payer, Exceeds the Maximum Days Supply Allowed, Non matched cardholder ID
- Name and dose of the medication. Is it covered under their plan? (Is it on formulary, OTC, covered by MA instead)
- When was it last successfully filled? When was the last attempt to fill? Is this a new medication?
- What pharmacy do they use? Name and phone number. Is this a preferred pharmacy under their plan? Is it a LTC pharmacy, potentially not in network with their plan?
- Are they completely out of the medication or is there a supply yet, how long?
- Is this the first time they’ve had issues filling it?
What type of medication are they filling?
Part D:
- Call the pharmacy
- Obtain any of the above information the client was not able to provide.
- What is the rejection code the pharmacy receives?
- i.e., Patient is Not Covered, Prior Authorization Required, Refill too soon, Filled After Coverage Terminated, Medicare Eligible -Client Must Enroll in Part D, Submit Bill To Other Processor Or Primary Payer, Exceeds the Maximum Days Supply Allowed, Non matched cardholder ID
- What billing information are they using to bill (BIN, PCN, ID, and Group)?
- Call SHIP
- What is the current drug plan? Has it changed recently? What is the billing information (BIN, PCN, ID, and Group)? Do they have LIS or extra help and what level are they? - reference SHIP QR.
- If no Part D drug plan but showing extra help, call to LINet and ask if they are eligible to use the program for the current month.
Part B or DME:
- Call the pharmacy
- Obtain any of the above information the client was not able to provide.
- What is the rejection code the pharmacy receives? Are they billing Part B? Are they in the network of providers for Part B? Is this a Part B covered service or supply?
- What billing information are they using to bill?
- Call SHIP (Part B department) or the Advantage Plan - - reference SHIP QR.
- Are they able to see the attempt to bill Part B services?
- Why is it not going through?
Over the Counter (OTC) Medication (For Medical Assistance enrollees):
- Does the pharmacy have a prescription for this?
- Is the medication on the OTC formulary? (Managed care of MA fee for service)
- Has the pharmacy contacted MHCP Provider Resource Center or the Managed Care Organization pharmacy help desk to see if there is a certain brand they should be filling or to get assistance with their billing issues?
Need additional help?
Contact the Tier 3 Support team through the support chats.
Limited Income NET Program (LINET):
When to use:
The Limited Income NET Program (LINET) is a Medicare program administered by Humana that provides immediate prescription coverage for people on Medicare who qualify for MA or LIS/Extra Help and have no Part D coverage.
Enrollment in LINET is temporary, usually for 1 to 2 months. This provides the beneficiary time to choose a Medicare Part D prescription drug plan that best fits their needs. If the beneficiary does not select a plan within this timeframe, Medicare will enroll the beneficiary into a benchmark plan.
Steps to take:
- Call SHIP to confirm what they are showing. (ONLY FOR SHIP: 1-866-934-2019 (SHIP ID)--anyone else, including pharmacies need to dial the main line.)
- When was the last Part D drug plan? Why did it end?
- If no plan, did they opt out?
- Any other coverage showing?
- Extra Help showing at Medicare?
- When was the last Part D drug plan? Why did it end?
- If SHIP shows Extra Help AND LINET at Medicare, call the pharmacy and provide LINET billing information.
- If not, consult with the Client Services Center (CSC) to confirm the case is appropriate for LINET.
LINET Help Desk: 800-783-1307 (TTY: 711), Monday-Friday, 8am - 7pm., Eastern time.
Medicare’s LINET Pharmacy Resources - Humana
Medicare.gov:
If Medicare.gov shows LINET, LIS, or Full Dual status AND the person does not have Part D coverage, the pharmacy can use the following information to bill LINET for the prescriptions:
- BIN: 015599
- PCN: 05440000
- ID: Beneficiary's Medicare number (Also called Medicare Beneficiary Identifier or MBI)
- Group ID: leave blank
MA or MSP in MMIS:
If MMIS shows that a person is eligible for MA (no spenddown), MA (spenddown met), or MSP but does not show LIS/Extra Help yet in Medicare.gov, AND they have less than 3 days of medications, one option is an immediate need override (also known as 21-day override). Refer to the CSC by chatting the Medicare and Benefits support chat. The CSC may need help getting Best Available Evidence to show eligibility.
If not yet eligible or eligibility unknown:
Screen the person to determine if they would be eligible for LIS/Extra Help and if so, complete the online LIS application. Inform the person that if eligible for LIS, it will be retroactive to the 1st of the month in which they applied, and they could receive reimbursement for out-of-pocket costs paid during that time.
If caller is removed from MSHO:
If the caller is removed from MSHO, they have 90 days of Medicare drug coverage. Please transfer this issue to Tier 3 Support.