Summary
The Medicare Prescription Drug
Emergency Guarantee Act

The Medicare Prescription Drug Emergency Guarantee Act would provide uninterrupted access to medicines for seniors and persons with disabilities who enrolled in new privately-run Medicare drug plans. This bill is intended to preserve access to medications and prevent beneficiaries from being penalized as a result of poor program design or problems created by the agency or the private drug plans.

The legislation would:

• Require all private drug plans to provide an initial prescription fill of up to 60 days or as often as necessary when the drug is not covered or when the pharmacist is unable to confirm plan enrollment.


• Require that a uniform standardized notice be given when a medication is not covered by the plan. The notice must clearly explain (1) how to file an appeal; (2) how to determine which private plans cover their medicines; and (3) how to switch to a more appropriate plan. It assures that beneficiaries who file the appeal continue to receive their medications during the appeal process.


• Protect against “bait and switch” tactics by private plans preventing them from dropping covered drugs from the formulary, setting up new barriers to access, or increasing costs to beneficiaries during the year.


• Require Medicare reimbursement for third parties, (e.g., states, charities, or family) that pay for cost sharing or drugs that are denied, or overcharged as a result of administrative failures.


• Allow all seniors and persons with disabilities whose drug is not covered by the plan to move to a more appropriate private drug plan during the year. Low-income beneficiaries will still be able to move monthly.

To guarantee that beneficiaries do not leave pharmacies empty-handed, the legislation would allow pharmacies to bill Medicare directly for prescriptions filled during the transition period, and receive prompt payments. In addition, it would require that Medicare recoup the payments from the private plan and apply sanctions to plans that do not provide medically necessary services, fail to meet contractual obligations under Medicare, or violate Medicare’s marketing guidelines.

The Medicare Prescription Drug Emergency Guarantee Act would also require a MedPAC study on whether private plans are meeting the needs of low-income beneficiaries.

Prepared by the Committee on Energy and Commerce 2125 Rayburn House Office Building, Washington, DC 20515