Quick Reference Guide for Behavioral Health Consumers
on Medicare Part D


The Office of Mental Health and Substance Abuse Services (OMHSAS) has issued useful guidelines to explain just how to deal with the difficulties that currently exist, with older consumers using Medicare Part D.


General Information

PA Department of Public Welfare
The Office of Mental Health and Substance Abuse Services (OMHSAS)

Issue 1

What to do if you cannot get your prescriptions filled at the pharmacy right away and you believe that it is an emergency:
Please call or have your pharmacist or the doctor who wrote you the prescription to call 1-800- 525-0674 and ask to speak with Aidan Altenor, Director of the Bureau of Hospital Operations, immediately

Issue 1A

What to do if the pharmacist charges a co-pay you believe is too high:
If you receive Medical Assistance and Medicare, you should not be charged more than $5 for a prescription---- you should tell the pharmacist that Medical Assistance will pay for the additional co-pay amount above the client-share

Issue 2

What to do if you do not know what Prescription Drug Plan or Medicare Advantage Plan you’ve been assigned to:
Please call 1-800- Medicare (1-800-633-4227) to ask questions about your PDP or Medicare Advantage Plan

Issue 3

What to do if you need assistance enrolling with a Prescription Drug Plan or Medicare Advantage Plan:
Please call any of the following numbers for assistance:
  • 1-800- Medicare (1-800-633-4227)
  • PA- Apprise Program 1-800-783-7067

Issue 4

What to do if you want to apply for the Low-Income Subsidy:
Please call any of the following numbers for assistance:
  • Social Security Administration 1-800- 772-1213
  • 1-800- Medicare (1-800-633-4227)
  • PA- Apprise Program 1-800-783-7067

Issue 5

What to do if you have general questions about Medicare Part D:
  • 1-800- Medicare (1-800-633-4227)
  • PA- Apprise Program 1-800 783-7067

Medicare Part D
At the Pharmacy
Quick Provider Reference

What to know at the Pharmacy as of January 1, 2006
  • Patients are entitled to refills for drugs that they are already taking

  • If there is confusion about whether the patient is enrolled in a Prescription Drug Plan (PDP) at the pharmacy, the patient can receive drugs through the Part D Point of Sale Protection Plan. The POS plan is initiated by the pharmacist. Patients will need to have at least 1 photo ID card

  • If the pharmacist refuses to refill a prescription for any reason, the patient is entitled to a one-time 30-day refill

  • If the pharmacist refuses to refill a prescription, the patient should request/demand that the prescribing physician be called. The reason for the denial should be communicated to the patient

Medicare Part D
At the Pharmacy
Quick Reference for Behavioral Health Consumers

What to know at the Pharmacy as of January 1, 2006
  • You are entitled to refills for drugs that you are already taking

  • If there is confusion about whether you are enrolled in a Prescription Drug Plan (PDP) at the pharmacy, you can receive your drugs through the Point of Sale (POS) Protection Plan through the pharmacist. You will need to have at least a photo ID card

  • If the pharmacist refuses to refill a prescription for any reason, you are entitled to a one-time 30-day transition refill

  • If the pharmacist is still unable to refill the prescription, use the solutions listed in under the heading Emergency Prescription & Co-Pay Guidelines

Who is Dual Eligible?

Are you Dual Eligible?
An individual is considered "Dual Eligible" if they receive Medicare and Medical Assistance benefits. Pennsylvania residents who are dual eligible and are having difficulty getting medications or are paying more than $5.00 in "Client Share" co-pays are eligible for Emergency Drug Supplies and assistance in paying for inaccurate co-pays as outlined below.

Emergency Prescription & Co-Pay Guidelines

What to do if you cannot get your prescriptions filled at the pharmacy right away and you believe that it is an emergency:
  • Inform your pharmacist that a 5-day emergency supply is available through Medical Assistance. All pharmacists in Pennsylvania were notified of this reimbursement through Medical Assistance. This emergency reimbursement for a 5-day emergency supply of medications came into effect January 17, 2006 and is in effect until January 31, 2006.

  • If there are still problems and the pharmacy is unable to give you a 5-day supply of medication, call or have your pharmacist or the doctor who wrote you the prescription call 1-800- 525-0674 and ask to speak with Aidan Altenor, Director of the Bureau of Hospital Operations, immediately.
What to do if the pharmacist charges a co-pay you believe is too high
If you receive Medical Assistance and Medicare, you should not be charged more than $5 (client -share) for a prescription---- you should tell the pharmacist that Medical Assistance will pay for the additional co-pay amount above the client-share.