Pharmacy Procedures for Verifying Medical Assistance Eligibility for Dual Eligibles
In response to the calls and inquiries received by the Department of Public Welfare concerning individuals deemed as dual eligibles who are attempting to fill their prescriptions, but have neither a Medicare card or Medical Assistance (MA) ACCESS card in their possession, we are offering providers the following information.
If you are having difficulty determining Medicare eligibility, there is a toll free number now available for pharmacists, 7 days a week, 24 hours per day. The number is 1-866-835-7595.
If you are unable to access this number, you may verify Medicaid eligibility and determine if they are a dual eligible recipient using the MA Eligibility Verification System (EVS).
There are several ways to utilize the EVS to verify Medicaid eligibility. Two of the most common access methods are the PROMISe™ Internet and a toll-free telephone number (Automated Voice Response System). The following are basic instructions for accessing EVS via these methods.
How do I use the PROMISe™ Internet to verify a recipient's Medicaid eligibility?
- Access the PROMISe™ Internet at: http://promise.dpw.state.pa.us
- Click the PA PROMISe™ Internet link
- Complete the Login ID and Password fields with the ID and password you created during the website registration process, and click the Log on button
- Note: If you have not yet registered to use the PROMISe™ website, click on the Create your user account now, link and follow the instructions.
- Click the Eligibility Verification link
- Enter the Recipient ID and Card Issue Number from the ACCESS Card, or the recipient's SSN and date of birth, or the recipient's first name, middle initial, last name, and date of birth
- Type or select the date(s) for which you are verifying eligibility
- Scroll down to see the eligibility response, the message, "Recipient is dual eligible," will appear in the Message Text box, under the Eligibility Detail portion of the eligibility response, if the recipient is dual eligible.
How do I use the Telephone (AVRS) to verify a recipient's Medicaid eligibility?
- Using a touch-tone phone, call 1-800-766-5387 and follow the prompts.
- Eligibility may be requested by using the Recipient ID and Card Issue Number, or the recipient's SSN and date of birth, or the recipient's first name, middle initial, last name and date of birth.
- Continue through the menu, if the recipient has Medicare Part A and/or B coverage, this information will be returned.
In order to determine which Prescription Drug Plan (PDP) an individual may be enrolled in, go to http://www.medicare.gov/
- Scroll down and click on Compare Medicare Prescription Drug Plans.
- Click on find a Medicare Drug Plan, enter all identifying information and the correct PDP should be returned.
As a reminder, the following drugs continue to be covered by Medical Assistance as they are excluded under Medicare Part D:
- Over the Counter (OTC) drugs
- Agents when used for the symptomatic relief of cough and colds (applies only to children under 21 years of age)