Question: Do R.Ph.s Need to Waive Copays for Medicare - Medicaid Dual Eligibles?

Answer: Many states today require copayments for Medicaid prescription drugs, but pharmacists are often obligated to waive the copayment for patients who say they cannot afford to pay.  While not necessarily the intent of state Medicaid policy, in some states it has become commonplace to waive copays on a routine basis.

The Medicare Modernization Act changed this practice for “dual eligibles.”  Dual eligibles are current Medicare-eligible beneficiaries who are receiving Medicaid prescription drug benefits. These patients will lose their Medicaid prescription drug coverage on December 31, 2005 and be rolled over to Part D starting January 1, 2006. Dual eligibles cannot expect that pharmacists will waive their copay because of financial hardship.  However, “pharmacies are permitted to waive or reduce cost-sharing amounts provided they do so in an unadvertised, non-routine manner” if the patient demonstrates financial need or fails to pay the required copay.  It is important to note that pharmacies cannot advertise in any way that they waive copays.

With as many as six million Medicare-eligible Medicaid patients being converted to Medicare Part D this fall, pharmacists must be prepared next year for patients unaccustomed to copayments being subjected to a small copayment fee structure.