Learning about LI NET and Transition Fills

What is LI NET? Certain low-income individuals covered by Medicare are eligible for a program called Low Income Subsidy (LIS), also known as Extra Help, that provides assistance in paying for their prescription plans (Part D of Medicare) and also gives them low co-pays at the pharmacy. Medicare beneficiaries who automatically receive LIS include individuals receiving any level of Medicaid and those who receive Supplemental Security Income (SSI). Others who meet the income and resource requirements may apply for and receive LIS by itself.

However, an individual must be covered by a Part D plan or a Part C (Medicare Advantage) plan with drug coverage to benefit from LIS. This leaves the potential for a gap between the time when a person is granted LIS coverage and the time when Part D coverage takes effect. The Centers for Medicare and Medicaid Services (CMS) addressed this issue through the creation of LI NET, the “Low Income Newly Eligible Transition” program. Those newly eligible for LIS who do not yet have Part D coverage or any other drug coverage, such as a retiree plan or Pennsylvania’s PACE program, can receive LI NET benefits. This is temporary coverage that lasts for only about 2 months. If the beneficiary hasn’t enrolled in Part D coverage by that time CMS will auto-enroll the individual. LI NET coverage discontinues when the Part D coverage starts.

How does it work? If you are covered by LI NET you will receive a welcome letter from Medicare or Social Security including the effective date for your coverage, a membership card, and instructions. Bring this to the pharmacy when you get a prescription. If your current information is in the CMS system, your claim will process immediately. If it is not, the pharmacist can verify your eligibility using the welcome letter, your current Medicaid award letter, or a letter from Social Security showing that you receive SSI benefits, and your drugs will be covered immediately. Depending on your level of assistance, co-pays for generic drugs will be $1.25 to $3.35, and $3.70 to $8.35 for brand names. If you incurred outof-pocket expenses on covered drugs while eligible for LI NET you can apply for reimbursement. You can get more information on this by calling LI NET customer service at 1-800-783-1307.

LI NET covers all prescriptions covered under Part D and any pharmacy can submit claims to LI NET. Remember that when your Part D plan starts, LIS covers only those drugs that are in the plan’s formulary.

What are Transition Fills?

If your Part D plan changed its formulary for 2018, you may find that one or more of your medications is no longer covered, or you may have moved to a new plan that does not cover a current drug. To give you time to switch to an appropriate drug that is in the formulary or to request a formulary exception, plans are required to provide a one-time “transition fill” of a 30-day supply (or less if that is what is prescribed) within the first 90 days after your plan or its formulary changes. Transition fills also apply if your plan covers the drug but there are new usage management restrictions such as quantity limits or requirements for prior authorization that would prevent you from getting the prescription filled. If you are eligible for a transition fill, the pharmacy will fill your prescription, but will receive an electronic notice from your plan that says that this is a transition fill. In some cases, the pharmacist will need to call the plan to get permission for the transition fill. You in turn will receive a letter from the plan that includes instructions for identifying appropriate substitutes, how to file a formulary exception request, or meet the usage management requirements. If you have a problem getting a transition fill your first step should be to contact your plan.

If you need assistance or want more information on topics covered in this article, or want help finding a prescription plan that gives you good coverage, an APPRISE counselor can help.

APPRISE is a free, confidential and unbiased service provided by the Pennsylvania Department of Aging, and locally under the auspices of the Chester County Department of Aging. APPRISE counselors are available to answer your Medicare-related questions. You can contact a counselor by calling your local senior center to set up an appointment or through the APPRISE Help Line at 610344-5004 option #2. You can also email us with questions at apprisechesco@ outlook.com.

— Information provided by APPRISE and the Chester County Department of Aging Services