**Medicare Prescription Drug Coverage**

**IHS/CMS Open Door Forum**

**November 8, 2005**

**2:00 p.m. CST**

Coordinator Thank you for standing by. At this time all participants are
in a listen-only mode. Today's conference is being recorded. If you have
any objections, you may disconnect at this time.

I would now like to turn the call over to Captain Robert Pittman. You
may begin, sir.

R. Pittman Good afternoon. Thank you all for joining us today on this
fourth in our series of open door forums on the Medicare prescription
drug coverage, or Medicare Part D. I'd like to take a few minutes and go
over some items and then we'll open it up to questions from the field.

I'm Captain Robert Pittman; Chief Pharmacist with the Indian Health
Service is Rockville, Maryland. On the line we have from the Centers for
Medicare and Medicaid Services, Roger Goodacre. Hopefully we'll be
joined by Irene Saccoccio from the Social Security Administration
shortly. I'd like to cover a few items. As you're all aware the local
trainings on Medicare Part D have taken place at sites across the
country. The Centers for Medicare and Medicaid Services has mailed out
the letters to the dual eligible, those with both Medicare and Medicaid,
the full dual eligibles, informing them of the prescription drug benefit
and the auto enrollment process, and asking them to go ahead and decide
if they're going to take any action. We've mailed out from our sites
letters to the dual eligibles asking them to come and bring their
letters into the local IHS travel our urban facilities so we can assist
them with the enrollment process.

Enrollment obviously starts on November 15^th^, so we're one week away
from the start of the process. We're less than a week away from getting
our credible coverage letters out to our beneficiaries. These of course
are the letters that inform the beneficiaries that IHS travel and urban
program prescription drug coverage is as good as Medicare Part D
coverage. For those who are still pending, again, those must be in the
hands of beneficiaries by November 14^th^.

We are asking folks to go ahead and start the process for enrolling dual
and those with extra help. We still do not currently have legislation
from ... to use federal funds, including federal funds provided to
contracts or compacted tribe for the premium costs. So we are still
anticipating that. We are still hoping it will take place before the
first of the year. But right now we're concentrating on enrolling the
dual eligibles and those extra help beneficiaries who have no cost to
us, those below 135% of the federal poverty level.

We have posted some new items on the IHS Web site, the
www.pharmacyissues.IHS.gov. We also anticipate some new items tomorrow
and that will include the list of planned contacts, and the plans by
area. Those items were already sent out to your area coordinators, but
we will be posting them on the Web site so that everyone can take a look
at those.

With that I will go ahead and turn the call over to Roger Goodacre from
the Centers for Medicare and Medicaid Services to provide you some
updates from CMS.

R. Goodacre Thank you very much, Robert. Good afternoon, everyone. I
just want to brief everyone on a couple of issues that have come up, or
that we've received questions about. They are principally in three
areas. The first being the Plan Finder issues and what's developing
around the Plan Finder. The second being facilitated enrollment issues
that is situations not auto enrollment but facilitated enrollment, and
that is enrollment that will take place later in the year when
individuals who are otherwise eligible because their QMB's or SSI
beneficiaries are partial subsidy recipients become enrolled in plans.
The third is questions surrounding group payer matters.

Let me chat briefly with everyone about Plan Finder issues. A couple of
things that are coming up that would be useful for people to know.
Tomorrow at 3:00 there is a Web cast planned for the Plan Finder. You
can find details about that by going to www.cms.hhs.gov, and on the
training link there will be information posted about how to get to that
training. The latest information again that I have is that is scheduled
for tomorrow at 3:00 eastern time. I think that would be valuable to
look at if people have the opportunity to do that.

There's also an on line demo on the Plan Finder that's available at that
site as well, and it's currently available, and I'd suggest that people
if they have the opportunity to take the time and check on that as well.

I guess even more broadly we do have a TV show coming up, not planned or
directly speaking to the Plan Finder, but about the benefit in general
that you might make everyone aware of, and that's scheduled for
Saturday, November 19^th^. Captain Pittman and I had a little bit of a
conversation about the time. I believe it's 6:30 eastern time on
Saturday the 19^th^. We'll confirm that time by e-mail with Captain
Pittman, but that is the time that we currently have.

A couple of observations about the Plan Finder. We have had a number of
questions about using the Plan Finder to access information generally
about the individual plans formularies. I have been informed by our Web
master, or our team lead in that area, that CMS will not be posting the
formularies for the plans through the CMS Plan Finder, nor will CMS be
posting the general formularies for the plans on any of its sites, that
is CMS sites. Information broadly about the plans formularies will have
to gotten through the plans themselves individually at their Web sites.
I know that's presented some difficulties for everyone, but at this
point and time that is the current CMS plan for providing information,
or for people to get information about individual plans formularies.

Another issue that's been raised about the Plan Finder is pricing, and
individual drug pricing. As everyone who's looked at the site knows that
information has not been available, in fact it became available
yesterday. That information is there. I know that there was some
difficulty with the site yesterday as many people were attempting to
access the site because that information had become newly available.
That appears to be relatively resolved now. I know there was problems
simply getting on and then problems with the speed of access, but those
problems appear to be generally resolved, and that information is
currently available.

In another area on the Plan Finder questions have been raised about
finding out about the status of the enrollment of an individual in a
particular plan. That is obviously a particular concern to your group
for people who are auto enrolled, and receive their auto enrollment
letter notice, will you be able to use the Plan Finder and determine
what the status of their enrollment is, and what plan they're enrolled
notice.

> I might note that, as Captain Pittman indicated, everyone who's going
> to receive an auto enrollment notice should have received it by now.
> And you should also be aware that those notices were printed on yellow
> paper. So if individuals talk to you about the yellow notice they've
> gotten from CMS or from a plan that should be the notice that they're
> speaking about. The attempt here was to make it as easy as possible to
> identify that letter by the color of the paper.
>
> Regarding the Plan Finder and auto enrollment, the information won't
> be posted until the end of this month, that is the end of November, on
> the second level of inquiry there on one's current status. It's going
> to take us that long to have that information uploaded to the system.
> But starting at the end of November you'll be able to determine
> someone's plan status simply by going to the Plan Finder in the event
> that they don't have that notice or that yellow sheet of paper.
>
> The same will be true for people who have enrolled for extra help or
> applied for extra help with SSA. Those individuals who have been
> approved and found eligible for extra help that information about
> their premium sharing will also be posted on that site, and you'll be
> able to determine by looking at that site what level of partial
> subsidy that would be available, what premiums or co-pays they would
> have. It's our intention to upload that information as it becomes
> available from SSA. We will get that information, I think we get data
> from them and I'm not sure whether it's daily or weekly, but we'll
> upload it as quickly as we can.
>
> Let me turn briefly to another question that I heard was of some
> concern for people, and that is what we call facilitated enrollment.
> Again, this is a situation that's not going to develop until later in
> the spring, so I don't want to confuse the issue here, or raise an
> issue that's of less than immediate concern, but this is not an issue
> that will come into play until slightly later in the spring, although
> I understand that people have concerns about it. That is what about
> individuals who are found by SSA eligible for extra help, but not full
> extra help, that is they'll only get a partial subsidy for their
> premium. If those individuals do not enroll in a plan by the end of
> the initial enrollment period, by May 15^th^, they too will be auto
> enrolled in a plan. It will be called facilitated enrollment for those
> individuals.
>
> The concern is that what will happen if those individuals are enrolled
> in a plan, and as we suggested they won't be eligible for a full
> premium, they'll only be eligible for a partial premium, will they
> suddenly be getting bills, and will they be forced to have money
> deducted from their social security check or pay premiums. The answer
> is as follows. Firstly, they'll get a letter just like everybody else
> and that letter will allow them the opportunity to decline the program
> should they so choose, and that would simply take it off the table for
> them as any issue of payment at all. Secondly, it is not our intention
> to at any time have a premium deducted from an individual's social
> security check. What they would receive is a notice from the plan that
> they begin to be billed by that plan, unless they decline the
> coverage.
>
> At this point and time it's going to be an issue of largely outreach
> and education for us to undertake vigorously at that point and time.
> But I did want everybody to know that it is on our radar screen, and
> we understand that it will affect a certain number of people and that
> we're prepared to help with that.
>
> Then the final question that I've heard that's been raised surrounds
> group payer issues, "What about tribes that want to make payments for
> individuals?" As we just discussed, for people who enroll and who are
> going to pay premiums there really are two basic ways, one is to have
> the premium deducted from your social security check, and the second
> is to be build by the plan. The question is if a tribe wants to be a
> group payer and deal with it in that fashion what do they need to do?
> At this point and time, after checking with our coordination of
> benefits people, we have only provided plans with a very broad
> guidance that they're going to have to work with individuals, or to
> have to work with other payers.
>
> So at this point and time we're left with the direction that
> individual tribes, after doing their analysis and determining which
> plans that they feel would be best for people, or are going to be best
> for their tribal members, they're going to have to contact the plans
> directly, and probably work out with each individual plan what the
> best way for that plan to work with them to pay to be a group payer
> for those individuals would be.
>
> I'll make available to IHS headquarters to Captain Pittman the
> guidance that we've provided to plans for that, but it is very broad,
> and it basically indicates that the plan will make the best
> accommodations that it can with the group payers that it deals with in
> this area. So we don't have specific guidance for that right now other
> than that general guidance.
>
> So those are the three areas I wanted to talk to briefly: the Plan
> Finder, that facilitated enrollment issue in the spring, and the group
> payer matter. Robert, let me turn it back to you.

R. Pittman Thank you, Roger. For the IHS and tribes and urban programs
Pam Schweitzer from our Office of Information Technology in Phoenix,
Arizona, is working with the plans that she has received to work on a
group payer process. We are asking that if tribes contract or sign
agreements with plans that are not currently signed up with IHS, that
they let myself or Pam Schweitzer know so she can also contact those
plans and start the process to make sure that they are able to do a
group payment process, and that we prepare our PMS for the billing
process.

So if you have any plans you're signing agreements with that IHS does
not, please let us know that and we can start you along on that process.
At this point I would go ahead and ask to open up the floor to
questions. We would ask that anybody asking questions please identify
yourself, and the site that you're from.

Coordinator The first question is from Patricia Olson, your line is
open.

R. Totachen This is Roland Totachen with the Area Office, I'm here with
Patricia as well. My question is to Roger. When you were talking about
the facilitated enrollment you said that the patient would not have
their check deducted, their monthly payment, but yet they will receive a
bill. If the patient does not respond, let's say, the second time or
around, or maybe two months passed since they got that bill, is there
still a possibility to go ahead and have the patient still say, "Well I
choose not to enroll in a plan because I cannot afford it." Or are they
going to be forced into paying that first month's premium?

R. Goodacre I don't have a specific answer to that. That is obviously a
situation that is probably eight or nine months out from us right now,
but I can't imagine that -- the Medicare plans wants to be advantageous
to its users and not fiscally burdensome, or not something like that.

So I am sure that we'll have some sort of exceptions process to deal
with the circumstance in which those individuals whom we're not able to
educate, and were not able to decline the coverage appropriately won't
be billed, and I'm sure we'll be able to work something out.

R. Pittman We're also encouraging sites as you sign folks up for extra
help we do want you to ideally maintain a listing of those individuals
and go back to the CMS Web site periodically and determine the status of
those individuals; have they been approved for extra help and have they
signed up for a plan. If so, because there was no cost to them, that's
fine. And for those who haven't, obviously we may need to make some
decisions on those individuals come late May or early June and sit down
with those individuals and help them decide whether or not they want to
sign up for a plan and who might be able to pay the premiums. But please
do keep those lists of individuals you're assisting with the extra help
process, and it will may life a lot easier as we go down the road.

Coordinator The next question is from Tracy Jones, Chickasaw Nations.
Your line is open.

T. Jones I have a question regarding the regions, we're a little
confused on if the patients are literally restricted to the regions
within our state boundaries, or is it the bigger regions? It was hard to
see on the map.

R. Pittman For selecting a plan I'm assuming you're talking about which
plans that an individual can sign up for. Obviously the smallest area of
a region, a prescription drug plan region, or an MABD region is a state.
Obviously if the individual only receives their care at one or more
facilities that are located within that state or within that region you
may want to sign them up for regional plans. But if there's a
possibility they may use healthcare facilities in two or more regions,
or in our cases in two or more states, if they're not in the same region
you may want to think about signing those individuals up for a national
plan. That way you make sure that they can get healthcare services and
it can be reimbursed no matter where they go since that plan is a
nationwide plan. Does that answer your question?

T. Jones Yes. So you would recommend a national plan as opposed to a
patient -- we have some patients who literally get care in three states.

R. Pittman We have a number of individuals, especially those around the
Navajo area, and the Phoenix area, who may go to many different states.
There are some regions such as the northern area which have seven states
in the region. So for those folks they may find that it's very unlikely
that many of their folks will ever wander out of their region. So that
regional plan may be sufficient for many individuals. Again, if you're
on the border or near a state line, you may want to first consider a
national plan to protect your patient.

Coordinator The next question is from Charla Carriere from Washoe Tribal
Health Clinic. Your line is open.

C. Carriere You had mentioned the fact that the formularies were not
going to be listed on the CMS center, and I went on there today and I
put in some medication because I'm trying to identify from our
pharmacist what are the most expensive medication we use, what is the
most ordinary ones we use, and I went in there and it actually does give
you the plan that will fill those prescriptions. I'm kind of concerned
because I was told when I went to a training that we could only use four
different insurance companies that were for Nevada. Then I did a
printout from Medicare and they show about 15 we can choose from. So do
you have an answer for that?

R. Pittman Certainly. Obviously the Plan Finder will allow us today to
go in and enter medications up to 25 medications for a patient, and it
will provide an estimated cost for plans for those medications. So you
can generally expect those medications to be on the formularies for
those plans.

In some cases if the medication is not on the formulary it will give you
an estimated cost for the drug, one that CMS has estimated, and you
won't necessarily to be able to be reimbursed for that. The whole goal
for us was to hopefully go in ahead of time and generate some paperwork
for the patient so when the patient came into the clinic we could say,
"These four plans will meet your needs, they have your drugs on the
formulary, there's good reimbursement, which of these plans would you
like to sign up for?" We could help them with the enrollment process
using the electronic or on line applications.

What we will be doing is we will be trying to identify the plans that
IHS and the tribes have, and the link to those plan's Web sites that
show the actual formulary. As soon as we have those available we will
also be going in and looking at the top 100 drugs from the IHS
standpoint, the drugs we order most from the prime vendor, and trying to
list which of the plans offer which of those drugs to hopefully make
your lives a little bit easier. But obviously you can make a good
estimation using the Plan Finder and the tool that's up now, but it
won't necessarily give you all of the information you might need.

Now you had mentioned the different plans in your particular state,
there's a couple of different ways to go about the various plans.
Obviously there are a lot of freestanding prescription drug plans, or
PDP's, most of us are looking at the plans that are eligible for dual
eligibles first, and generally that's somewhere between five and 15 or
so plans per region, and also the national plans. Obviously we want to
concentrate on those plans for our folks because many of your dual
eligibles will be considered for those plans. We don't want to sign our
dual eligibles up for other plans because there may be an issue with the
premiums that even if the premium cost is the same or lower, if those
plans are offering extra benefits the beneficiary or someone else would
be expected to pay the difference between the basic benefit and the
extra benefit.

> So we want to look at the plans that specifically state they're for
> dual eligibles and concentrate on getting our dual eligibles into
> those. We can look at other plans for the Medicare only beneficiary,
> but again we may want to concentrate on the plans eligible for dual
> eligible. Does that answer your question?

C. Carriere Somewhat. How are we going to know because we're going to be
sending letters out, well I know you've already sent letters out, but
we've had no response, but we've already identified our dual eligibles
and we are going to be sending letters out again. You said that there is
going to be some plans, and I don't even know which plans to contract
with to even tell them that they called us. Have you identified the
plans?

R. Pittman Certainly. When you go on the Web site, and again we'll have
this information posted on the pharmacyissues.ihs.gov Web site, but
right now if you go to the www.medicare.gov Web site you can see a
listing and it will indicate in the green section, I believe it is,
where there is no additional premium costs for the dual eligible
beneficiaries. So basically you can see those plans with a dot in them
are going to be those plans that you could sign your dual eligibles up
for in your state. That way you'll know the organization such as Humana
or United Healthcare, or whatever the entity is you're signing the
agreement with, but you'll also see the individual plan under them
because the entity may have five or six plans, but only one of them may
be eligible for the dual eligible.

Again, if you need assistance with that process give me a call or an
e-mail and I will e-mail you your state's plans and identify for you
which one of those are for the dual eligible. But it is up on the Web
site and take a look at that and see if that might answer your question.

C. Carriere Could I have just one more short question? Whenever I went
to that training they said that we just had Humana, MedCo, Member
Health, and RX America was the only ones that we could contract with,
but we're a compact tribe. Then I was told by Rosie at CMS that actually
we can contract with anybody and not just those four, and I've only been
concentrating on those four.

R. Pittman Tribal entities can contract with as many plans or as many
organizations as they wish. We have advised tribes that they may want to
look at the lists of entities that Indian Health Service has already got
agreements in place with just because if you have an IHS site and you're
a tribal site you want to make sure that they have similar contracts in
place, but you may contract with or get agreements with as many claims
as you choose.

What you may want to do is go to that Web site and look and see which
plans are in your region or in your area, and then concentrate your
efforts on those plans that are available to the dual eligibles first,
and then as you have time you may want to expand to other plans that
offer a good reimbursement rate and good formularies.

Coordinator The next question is from Terry Green, Alamo Navajo Health
Center. Your line is open.

T. Green I just have a real basic question for you. Since enrollment
starts next week where do we actually get the enrollment form? I haven't
seen those on line and I've been contacting the companies that have
contracts with they don't have them available right now. Where do these
...(audio)?

R. Pittman Roger, do you have information about the enrollment forms? We
may have lost Roger. Basically the enrollment forms will be available on
line starting November 15^th^ through the CMS Web site. Enrollment forms
will also be available at the individual plan Web site so that people
can enroll by going to the Web site of the plan, and the enrollment
forms will be there also. And beneficiaries can enroll by contacting the
1-800-Medicare line and going through the enrollment process with one of
the operators there. But it will be available on the CMS Web site, and
you will be able to click on that and complete the application on line
or go directly to the Web site of the plan that you're interested in
enrolling the patient in.

T. Green So you're saying that starts on the 15^th^?

R. Pittman That will start on November 15^th^, that is correct.

R. Goodacre This is Roger. I'm sorry I did get cut off slightly there.
Yes, in fact it will all be available the 15^th^. If you look at the
Plan Finder now it notes that on the enrollment site itself that it
won't be available until the 15^th^.

Coordinator The next question is from Carol Goodin, Feather River Tribal
Health. Your line is open.

C. Goodin My question is when we have put dummy patients through the
system with a moderate number of medications and disease complexity I'd
actually gotten back a response that says, "No plan will cover these
medications." My request is that if the program would be able to offer a
next best coverage if there's not a single plan that will cover all of
the meds, will it at least identify the plan that would cover most of
the medicine?

R. Pittman Roger, do you want this one or do you want me to take it?

R. Goodacre You first, Robert. If you don't mind.

R. Pittman The way that the Plan Finder is expected to work on the
15^th^ is that basically if there is a medication or medications that
the patient is taking that are unavailable through the plan it should
make an estimated guess to the cost of the medication, it's an average
cost, and will basically provide for you the plans with that cost
assumed in the calculation. You may have a whole number of plans that
don't offer all of the medications, but you want to be able to compare
on average what the cost is.

Obviously as we get closer to having the formularies available and the
links available you may be able to enter in and identify which plans
offer most of the medications, and then go and see what the individual
plan tiering is for price costs, and alternative medications that are
available through the different plans. But the system should allow you
to get some kind of estimate on which of the plans might best meet your
needs even if they don't provide reimbursement for all of the drug.

C. Goodin The response that I did actually get was, "No plan covers all
of these, but these are the pharmacies that you can go to that offer
some plans." So is that in the works then?

R. Pittman That is my understanding that it should be up and running by
the time the program starts on the 15^th^ because it's supposed to put
in some kind of alternative. For example, if you had six very expensive
medications, and then you offered a very inexpensive medication like
hydrochlorothiazide, you would hope that the system would not kick you
out saying there is no plan that carries all of these because it didn't
have hydrochlorothiazide you really want to know what's going to cover
the most expensive medications. If for some reason you can't be
reimbursed for that very cheap medication than you may end up just not
billing for that one. That may be how you have to look at that in the
short term until that's up and running is to put in your most expensive
medications first and see which plans are identified. But, yes, it
should eventually be able to tell you which medications are not covered,
but it's put in an approximate cost for them.

Coordinator The next question is from Alene Gighan from Sioux Tribe
Center. Your line is open.

A. Gighan I have a question about the creditable coverage letter. What
if they get it later than the 14^th^ if they receive it later, and does
it have to be sent out annually?

R. Pittman Certainly. Obviously the regulations from CMS are that the
credible coverage letter be received by the beneficiaries by November
14^th^. The rationale is that the beneficiaries need to make a decision
on whether or not they need to sign up for a Medicare prescription drug
benefit. If they know that their prescription drug coverage is as good
as Medicare than they can make a decision whether or not to sign up. If
they don't know then they don't know how to make a decision. So we need
to get the letters out to them by the 14^th^ so that they know that they
are covered.

Basically CMS is going to be putting out additional information on how
we notify individuals annually that our coverage is credible. There may
be a variety of different ways that could be done if a plan is an
insurance plan, and they provide the beneficiary with a summary of
benefits annually, they may have some regulations related to including
the credible coverage statement ... Since we don't normally send an
annual benefits or annual coverage statement to our beneficiary, we may
have to find some other mechanism to assure that we get that letter out
annually.

But additional information is going to be coming out from CMS over the
next couple of months, and we will provide that information to you all
on the Web site as soon as it's available.

Coordinator The next question is from Carol Barbero, Hobbs Straus Dean &
Walker. Your line is open.

C. Barbero Rob, my question concerns IHS's efforts to get available for
tribal sites the same reimbursement rates that IHS received in the
contracts it signed. Could you give us a status report on which PDP's
have agreed to make the same rates available to tribal sites?

R. Pittman Certainly. As we were talking with tribes about the
prescription drug plans and the agreements that were signed tribes did
express to us that many tribes had not been offered agreements by the
plans, or if they had they had not made it to the appropriate
contracting official, and wanted to see if there was a way that they
could get contracts or agreements that were similar to those that IHS
has signed. That included issues such as: reimbursement rates for
pharmaceuticals, and other issues that IHS might have negotiated in its
agreements. We have talked with the plans about the possibility of
having a standardized tribal agreement that is very similar to, or the
same as the IHS agreement, but including the tribal addendum.

To date we have had some interest expressed from several of the plans,
but we have not received any notification from any of the plans as of
yet that they have those agreements ready and are able to go ahead and
send those out to tribes for signature. So I guess the answer right now
is none at this point, but we are still hopeful that we'll be able to
get many of the agreements that IHS has in place, and very similar to
the tribal agreements being very similar to the IHS agreements. We will
continue to post information as we get them. We will not be able to post
the agreements on the Web site because then that would be a release of
the information, but we will let the tribes know from the Web site and
through e-mails when the contracts are available and how to get them as
soon as we do have them.

Coordinator The next question is from Cynthia Larsen, Billings Area
office. Your line is open.

C. Larsen Just a quick question, Robert. I know you said something about
this at the beginning. Are you planning on setting out a synopsis or
crosswalk of what plans are available per area; what their sub plans
are; what are the national plans; which plans does Indian Health
Services have contracts with; contact information; Web site information;
phone number information, or is that up to us as individuals?

R. Pittman The short answer is yes. We will be sending that information
out. Pam Schweitzer has provided information by area to folks out in the
areas showing them the organizations and the plans under them. We will
be posting that hopefully tomorrow as soon as our folks in Albuquerque
can get it up on the Web site. The listing of the plans and the
organizations they're under, the contact list for the organization, and
we hope to link that to the entities that are eligible for dual
eligibles in that area also. So it should be basically an all inclusive
list that will help you identify who the plans are that are eligible to
you, which ones you might preferentially want to include, and look at
the ones that you have agreements with to narrow down the selection to
help you make some decisions.

> Additionally, if there are plans in looking at your state or your
> regional lists that it might be good for you to have negotiations with
> about an agreement, there will be a contact list up on the Web site
> which you can contact those plans.

C. Larsen One other question. Is it possible for somebody to put
together a quick time line again? I know that's a lot of published
information but as to the time line of the dual eligibles, the time line
of the Quimby/Slimby's, the time line of the LIS, and then any time line
that applies to the non-subsidy population. I guess one of the questions
I had, and I'm sure it's in our literature, but if a person signs up
with the plan through paying a premium February 28^th^ do they become
eligible March 1^st^?

R. Pittman We will go ahead and get a new time line up. We'll post it on
the pharmacyissues.IHS.gov Web site, and we will send it out to all of
the pharmacists and to the area coordinators to send out to all of the
sites.

Any time a beneficiary enrolls in a plan their plan benefit begins the
first day of the next month, so if they sign up the last day of February
they would start March, and if they sign up the last day of December
they start January. So the first day of the next month is when your
benefit takes place.

C. Larsen And the only exception to that is the full dual eligibles if
we get them in a plan November 21^st^ they're not going to start until
January 1^st^?

R. Pittman Well for this particular year any one who is signing up
between November 15^th^ and the end of December will start their benefit
January 1^st^. But the dual eligibles who are eligible to switch plans
monthly if they so choose, any given month that they change plans their
benefit will start the first day of the next month.

Coordinator The next question is from Charla Carriere, Washoe Tribal
Health Clinic. Your line is open.

C. Carriere We were talking about the dual eligibles and the ones that
say we don't get in contact with, or don't get in contact with us, and
they choose a plan for them automatically, what if we're not contracted
with that plan? That's what concerns me.

R. Pittman Certainly that is of great concern to all of us. There are a
couple of different possibilities. One, we want to encourage those
individuals to come in to the IHS Tribal Urban Clinic, and talk with
your staff about which plans you have agreements with and see if any of
those plans might best meet the patients needs based upon the drugs the
patient is taking and the reimbursement rates you're receiving. If so,
then go ahead and encourage the patient to work with you to sign up for
one of those plans that you have an agreement with.

If you find that patients have signed up with other plans, or that there
seems to be a number of patients who want to be in other plans, then you
obviously have the opportunity to sign agreements to be part of the
pharmacy network for those plans. In that case, obviously if you're a
tribal or urban entity you would work with your contracting official to
negotiate an agreement with the plan. If you're an IHS entity, and you
would like to see us negotiate an additional agreement contact me and we
will look at the plans we do not have and see if we need to add
additional plans. But obviously the contracting and agreement process
can take several months, so our top priority will be trying to encourage
patients to get into plans we already have agreements with, realizing
that our dual eligibles will have an opportunity to switch later on, but
if we don't have them in a plan we can bill by January 1^st^ we will not
be able to bill for their drugs.

Does that answer your question?

C. Carriere Yes that did. One other question that concerns me, too, is I
hadn't thought of it when you had stated the fact that if we fill out a
form for the \$2100 to help pay for the patients for help, and say they
only okay \$1500, so a portion of that may be charged towards the
patient. Well our Native American patients are not supposed to pay
anything, so how do we stop that from happening? How do we have control
of that?

R. Pittman Keep in mind we're only going to have our patients sign up
for the Medicare prescription drug coverage if there is no out-of-pocket
cost to them. For our dual eligible beneficiaries, those who are both
full dual eligibles and those who are partial dual eligibles, there is
not out-of-pocket costs, the state will be paying the premium, and there
is no co-insurance cost, there is no deductible. The co-pay, the one to
three dollars or the \$2 to \$5 basically we will absorb that part of
the bill when they come to the IHS or to the tribal sites for
healthcare. When we send them out for contract health services we will
absorb those costs through contract health services paying for those
costs.

For folks who are eligible for Medicare only who might be eligible for
the extra help, or even those who are not eligible for the extra help,
we will be looking at them on a case by case basis to decide whether or
not we wish to sign them up and pay the premiums for them. Currently
tribes have the authority to use tribal funds, non-federal funds, to pay
premiums for beneficiaries if they so choose. For IHS, again, we are
still waiting for that legislation from Congress to allow us to use
federal funds, or for tribes to use the federal funds through their
compact or contract agreements.

So, again, we're going to concentrate on the dual eligibles, the full
and the partial dual eligibles, and those who are eligible for extra
help who are below 135% of poverty, and therefore have no premium cost,
but for the others we're going to look at on a case by case basis once
we have the legislation.

R. Goodacre This is Roger. If I might add, clearly the letter that
anybody gets who would only be eligible for a partial subsidy will
indicate that they're able to decline that. So they'll be notified of
that up front before they receive any billing notice from the plan.

Coordinator The next question is from Rhonda Milton from Chugachmiut.
Your line is open.

R. Milton If we have a person that is currently on a drug plan, and
something awful happens in their life and their drugs change and they
need to change the plan, are you going to allow them to change? When can
they change? And how often in a year can they change?

R. Pittman Do you want to answer that, Roger?

R. Goodacre Well there's several circumstances here. As Captain Pittman
suggested earlier, if that individual has that misfortune is a dual
eligible person that individual can change plans on a monthly basis.
Other individuals, depending on their income status, may have other
circumstances which might allow them to change at least once in this
early period. But the typical individual will only be able to change
plans once a year during an annual period, and that period will take
place at the end of each calendar year. So those are the general
circumstances that will apply. Again, it will depend on the individual,
but people will indeed have opportunities to change plans.

R. Milton Will there be an emergency circumstance for these people that
can only change once a year if the necessity warrants, and they have
these huge costs for drugs for this condition they now have that they
did not, is there going to be any kind of an emergency basis that they
can ask for a forgiveness, or whatever you want to call it?

R. Goodacre There will be an exceptions process -- if the bottom
question here is that the plan may not cover the drug that the person
now needs?

R. Milton Yes.

R. Goodacre Well then there will be exceptions processes for with the
plan that people are enrolled in to ask for exceptions in circumstances
such as the one that you described. But to my knowledge there won't be
an exception to allow them to change plans for that. They would have to
deal directly with the plan that they're in until that annual enrollment
period comes up in which they can change plans if they chose.

R. Milton I have one other question. A lot of our elders up here in
Alaska, when you say the word computer they just kind of have the deer
in the headlight look. Now my understanding is they're only allowed to
apply for these programs on line? Is that correct, or are we going to be
able to use a paper?

R. Goodacre The answer is yes and no depending on how we're answering
the question. Yes you can use a paper process. I would strongly suggest
that for those individuals however that their first line of dealing with
us would be to come in and speak with you so that you can get on line
and help them that way. They, of course, can also use the telephone.
Individuals can call 1-800-Medicare to enroll as well. But there will be
a paper process, and individuals can get paperwork for the individual
prescription drug plans, they will send you an enrollment package if you
choose to go that way. But I think the best way would be for you to
encourage people to come in and speak with you about which plan would be
best for them, and which plan would best work with you and them.

R. Pittman Like the prescription drug card there will be an opportunity
to either ask the plans for the hardcopy or to download the application
off of the Web site and use that. We would encourage folks if they don't
want to do it on line with you to bring it in to make sure it is
complete. One, we want to identify which of our beneficiaries has signed
up for a plan so that we know that they're taken care of and we don't
have to worry about them anymore. But we also want to make sure that the
application is complete, and that the beneficiary doesn't' have a
delayed enrollment in a plan because the plan is trying to get
additional information from the beneficiary who may be very hard to
reach.

So ideally as Roger had mentioned, bring them in and go through the on
line application with them, and assist them with that process. If they
want to do a hardcopy, just print it out at your local printer and help
them with the process, or if they want to take it home and think about
it for a little while ask them to bring the completed application in and
go through it with them to make sure it's complete.

Coordinator The next question is from Leaann Romero, Kanza Health
Center. Your line is open.

L. Romero One thing that I'm really glad to hear on your call is that we
are targeting those dual eligibles and those that qualify for the extra
help because on the CMS side of the training I've received I felt like I
should be pushing and pushing but then being a Native American I
understand those patients that are over that income and that will have
to pay out of their pocket, and understanding their questions of, "Why
would I even pay for it when I have the IHS?" So that's the one thing
that I really appreciate that you clarified for me today.

Another comment I just wanted to make was for the individual calling
from Alaska asking the questions about when the enrollment time would be
up for them. With that because we are targeting the dual eligibles are
the people that qualify for the extra help, if I understand it correctly
they have an open enrollment period, is that right? So if these people
come into something they can change every month?

R. Pittman That is correct. The dual eligibles can change plans on a
monthly basis.

L. Romero And those are the people we're targeting so that should be
pretty easy for them if they do need to make a change.

R. Pittman Certainly. It will be an easy process. Ideally we're going to
try to encourage everybody to get signed up by the last day of December
so we can start billing on January 1^st^, especially for the dual
eligibles because we're going to lose the Medicaid reimbursement for
those folks, and we want to be able to bill Medicare to recover that
money.

But if people come in and we haven't had a chance to get to them until
February, March, or April, or even before May 15^th^, we want to get
them signed up with a plan if they're a partial dual eligible, or a full
dual eligible, or even some of the extra help folks, and get them in a
plan and make sure that they get the benefit they want.

We have pretty much a six month window to get everybody in, but of
course the sooner we get them signed up the sooner we can bill for the
services.

Coordinator The next question is from Charla Carriere, Washoe Tribal
Health Clinic. Your line is open.

C. Carriere You had said you were going to have a listing of the plans
that will tell you the entities for the dual eligibility, what site is
that going to be on?

R. Pittman It will be on the www.pharmacyissues.IHS.gov Web site. You
can also go right now to the CMS Web site to www.medicare.gov, and one
of the choices there will tell you by state which are the entities and
which are the plans. But we hope to be able to provide you some
additional information in addition to what's on that Web site to make it
a little clearer based upon the agreements we have in place to assist
you in that process. But most of the information is up there right now
where you could view it today.

C. Carriere That's what concerned me because I want to make sure our
dual eligibles get on the right plan. Like I said, that's who we're
targeting right now.

Coordinator The next question is from Cynthia Larsen, Billings Area
Office.

C. Larsen The first is a comment, we were just talking about how to
actually enroll into the individual plans, and we're pushing to go on
line, and we want them to come in. But realistically I think a lot of
the outreach is going to happen in the people's homes in the community
centers. So we're going to have to rely somewhat on the paper process
unless you've got the wireless computers going out with you. A lot of
times they're not going to come to us, we're going to need to go to
them. So having access to those hardcopy enrollment forms is going to be
key for some of our populations.

Second of all, just a comment, in our area we have unfortunately only
25% of our Medicare population is dual eligible. So we do have another
75% that we have to target after this first phase to get them on extra
help, or to talk to them about selecting a plan.

The third question I guess is, Robert, as we all know you did national
contracts, or IHS ... contracts, if a particular area decides that one
of those plans that we did not contract with may be beneficial in our
area, although it wasn't on a nationwide basis, can we enter into
contracts with them from an area standpoint?

R. Pittman We would be happy to have you contact us here at headquarters
and we would negotiate an agreement with a national plan for you, or
with a regional plan, but we are going to be doing the contracts for all
of the IHS sites here at headquarters. So if you see a plan in your
region please let us know that the plan is that you would like to work
with and we'll be glad to talk with them about an agreement. We want to
make sure we standardize the agreements that we negotiate across IHS,
even if it's just for your particular state. So we wanted to have the
same terms and conditions as we negotiate with all of the other
agreements. So please come to the headquarters, e-mail me or call me and
we'll go ahead and start the paperwork process.

Coordinator At this time there are no further questions, sir.

R. Pittman We did have some issues that we wanted to talk about. You'll
see on the Web site tomorrow there should also be a listing of issues
related to the point of sale package and RPMS. While waiting to see if
we have a couple of additional questions I'll go over a couple of these.

Obviously, Pam Schweitzer has been working with the various plans on the
point of sale technology to make sure we have everything in place, and
one of the questions she had received was, "Will the RPMS point of sale
software be able to transmit the Medicare prescription claims?" The
answer to that was, yes. The Office of Information Technology is in the
process of obtaining payer sheets from each of the CMS plans. The payer
sheets are used to make the formats needed to transmit the claim, and a
patch will be released in early December, along with instructions on how
to setup the format in a point of sale package.

By early November information including the insurers names and addresses
will be distributed to assist sites in the process of lining up the
insurers. This is really the reason why we need you to let us know,
especially if you're a tribal or an urban site, if there are other plans
you are negotiating agreements with, even if you don't have an agreement
in place yet, if you anticipate you will be having an agreement, please
let us know so we can obtain the payer sheets and start getting the
formats in place so that when that patch comes out for RPMS in December
that will be in place.

If you use another billing package besides RPMS please make sure whoever
handles your pharmacy billing package is in contact with the payers to
set that up in their system.

Another question we received is, "How will the claims process change for
pharmacy's transmitting electronic prescription claims?" Basically for
the pharmacies very little will change. As most of the changes occur
behind the scenes with the switching companies and with the TrOOP
facilitator. One new feature will be that they're going to add to RPMS
point of sale package for the eligibility transaction, this will enable
users to send the transaction to the true out-of-pocket costs
facilitator, or TrOOP facility to determine Medicare plan information.
This is not something we currently can do. Office Information Technology
is currently testing this feature. There is a fee for this process, and
the fee is \$.015, so one and a half cents per transaction, and that's
for all transactions including rejected transactions. So it will help us
identify what plan are patients are signed up with and the patient
information that we need to go ahead and process the claim.

Do we have any more questions at this time?

Coordinator Yes we do, sir. The first one is from Kris Locke of TTAG.
Your line is open.

K. Locke I had a question about the national plan. My question is what
makes a plan national, does that mean that they will actually have a
good pharmacy network in each state, or could a plan just be national
because it has mail order?

R. Pittman Roger, do you want to answer that?

R. Goodacre To my knowledge, Kris, they should have both. They should
both an on the ground network available as well as mail order.

R. Pittman That is correct. Basically the national plans are basically
plans that have a provider pharmacy network in every state, and meet the
requirements to have a national network, and they do offer mail order.
So basically if you had a patient who spent part of the time at your
service unit, and then maybe in a different part of the country, or even
just visit a facility that's an hour away, but happens to be in a
different region for the CMS PDP's or MAPD's, you would want to sign
them up for a national plan. Or you could sign them us as a regional
plan as long as that plan had plans in both regions. But a national plan
is a lot easier.

There are I believe ten national plans, and I think IHS has agreements
with about half of those. So we do have a good selection of national
plans. We don't want to discount using regional plans because there may
be regional plans that also are more inclusive benefit to our patients.
So we don't want to avoid regional plans where they're appropriate, but
we do want to make sure that the patient is covered if they happen to
travel, or spend part of the year in different parts of the country, or
visit IHS or travel facilities in different CMS regions.

So there will be an opportunity. A lot of us will use the national plans
but we do want to also consider regional plans.

K. Locke I had one other question related to that. If a person signs up
for a PDP in their region, but a neighboring state which is in a
different region has the same plan, it would be a different premium, but
it's not considered a national plan. Would that person be able to use
the neighboring state's PDP network?

R. Pittman It depends upon is it the same plan or is it the same
organization? What you may find is that there are plans, an organization
like Humana may offer different regional plans, and basically they are
slightly different plans and that's why they're listed as different
plans in different regions. If it's the same plan you may be able to use
that benefit across the two different regions. But we would want to
check with the plan provider if we anticipate that a person may go into
a different region.

Coordinator The next question is from Tracy Jones, Chickasaw Nations.
Your line is open.

T. Jones Actually, Robert, you more or less have answered my question,
it was in regards to claims processing and what would happen in point of
sale. So the TrOOP facilitator or the contractor, I'm not sure what
you're calling it now, but that will happen behind the scenes in point
of sale, is that correct?

R. Pittman That is correct. Basically the TrOOP facilitator or
contractor is working with CMS, the prescription drug plans, the
Medicare Advantage drug plans, and the carriers of supplemental coverage
to coordinate the benefits and to track the sources of the cost of
drugs. So basically it's looking at all of the different payments, and
where those payments came from, and it's trying to identify for folks
who's made the payments, what payments count toward TrOOP, and who might
be a secondary payer.

Coordinator The next question comes from Charla Carriere, Washoe Tribal
Health Clinic. Your line is open.

C. Carriere I was looking at the information I was given regarding
PDP's, and MA's, and PDS, what are the difference in those, and can we
contract with all three of them?

R. Pittman Well we have the stand-alone prescription drug plans, the
PDP's, and those are basically entities that are offering a prescription
drug benefit but no health benefit. We have the MA plans, the Medicare
Advantage plans, which have traditionally offered a health benefit, and
now those that are going to be offering a drug benefit in addition to
that are going to be our MAPD's, our Medicare Advantage Prescription
Drug plans. So we can have agreements with MAPD's or PDP's in many of
your agreements with IHS with the different organizations the
organizations have some PDP's that they contract with and some MAPD's.

So we do have agreements with MAPD's right now with Indian Health
Service. So it's a matter of where is your patient getting care. We
would expect that most of our patients are getting their healthcare
services from us, and therefore they only need to add a prescription
drug benefit. In that case we will sign them up for a prescription drug
plan, or a freestanding PDP.

If a patient is getting care already from a managed care organization,
one of the MAPD's, because they have some other health benefit, they may
choose to be signed up with the MAPD. If they're in a state where
they're signed up they may be automatically signed up for that MAPD and
not be given the choice. But if they choose to have their drug benefit
with that MAPD because they already get their health benefits from them,
then we can sign them up for that plan. We just need to make sure we
have an agreement to be a pharmacy network member for that particular
MAPD.

C. Carriere That's what I was wondering because it seems like when I
looked at the MA's it looked like they were all HMO's, the senior care
plus and the senior dimensions, and I thought we really actually do
state Medicare, I don't think we have any HMO's that we see of our
patients. Thank you.

Coordinator The next question is from Elizabeth Woodard at Round Valley
Indian Health. Your line is open.

E. Woodard My question is regarding clinics like ourselves who are
remote and don't have our own pharmacists or pharmacy, we are
dispensary, and we have our medications brought in from a pharmacy that
is 60 miles away on a daily basis though. So are there any special
considerations for us in that regard?

R. Pittman Absolutely. There are two situations which a dispensary, or a
facility without a pharmacy, might find themselves in. The first is the
situation that you're probably in right now where you send your
prescriptions out to a retail pharmacy network and you go ahead and pay
that pharmacy network for those services either through contract health
service dollars or another mechanism.

In that case what you would want to do is you would want to not
necessarily sign agreements with the plans yourself, but find out which
plans your retail pharmacy has signed agreements with because what you
would want to do is you would want to have your retail pharmacy go ahead
and bill the plans, do all of the paperwork, and then bill you for only
any remaining costs for those patients.

In most cases that would be the co-pay or any co-insurance, or any
deductible that you might see from those patients. It would reduce
contract health service costs, and free you up from the billing process.
The other way you can do this process is if you dispense the medications
yourself, choosing to do that either through a healthcare provider
dispensing the medication, or ordering the medication from the pharmacy
paying full cost and then dispensing to the patient and billing
yourself. In that case you would have to sign the agreements with your
own facility with the various plans, and then go ahead and do the
billing process that way.

You may find that it's much easier to use the first process. Again,
you'll have to make sure that if you're using a retail pharmacy, and
you're using contract health service funds that you have a CHS agreement
with that pharmacy, and that you're aware of what plans that pharmacy is
signed up with.

Keep in mind that even if you are a dispensary you are considered to
have credible coverage as part of the Indian Health system of care.

Coordinator The next question is from Valerie Chee, San Carlos Indian
Hospital. Your line is open.

V. Chee I was just looking at that Web site you gave us the
www.medicare.gov, and I saw the listing for the Arizona plans. How do we
identify for the dual eligible? How do we identify the plan specific for
those? Is it just about the deductible?

R. Pittman There is a piece on that chart, unfortunately I don't have
one in front of me that's complete, but I believe as you go over the
fifth or six column, I think it's green, it indicates there is no
premium cost for a full low income subsidy. So that will indicate that
for the dual eligibles there is no cost either, basically it's being
taken care of.

We will go ahead and highlight that column when we post it on the
Pharmacy Issues Web site so you're aware of which column that is, and so
you'll know which of those that have the dot in them are covered for the
dual eligibles.

V. Chee So you'll specify on your Web site, but right now it's not?

R. Pittman Right now it is but you have to look up at the header there
and identify which it is, but we'll go ahead and explain that both
verbally and we'll highlight it.

V. Chee The one from Arizona what I'm looking at are the Arizona plans,
and all of them have a monthly premium identified, there isn't one that
doesn't have any ...

R. Pittman Correct. They all have a monthly premium identified, but the
column after that should indicate whether or not the premium is no
premium for the full low income subsidies

R. Goodacre It's the second green column.

R. Pittman Correct. So if it has a dot in that second green column that
says there is no premium with full low income subsidies, then even
though the premium is shown that's the premium for folks who don't
qualify for any subsidy. Those who have the full subsidy or who are the
dual eligibles that premium is taken care of. So those are the plans
with that dot in them that they can sign up for.

V. Chee What I'm looking at doesn't show the green column, but I'll go
ahead and just search more on that. I'll look forward to the pharmacy
one.

R. Pittman Or give me a call in the morning and I'll be glad to walk
that through with you.

Coordinator The next question is from Lovetta Whitemouse from Fort
Thompson Indian Health Care. Your line is open.

L. Whitemouse We were looking at the Web site here and it seems to take
a long time to find the prescription drugs to pull them up. Is that
going to be improved, or is that how it's going to always be?

R. Goodacre Let me try to address that. There's clearly a lot of traffic
on that Web site in the last couple of days since we've introduced the
pricing information. I know that our Web folks are working assiduously
with our contractor to improve the speed on that. So hopefully in the
next several days you'll see a dramatic improvement.

Coordinator The next question is from Tracy Jones, Chickasaw Nations.
Your line is open.

T. Jones Yes. Robert, when you refer to the eligibility transaction
component and point of sale, this is the first I've heard of it just
today, but are we to liken that to like a WebMD contract that we have on
registration? I mean is it the same principle and we just need to go out
and find a vendor?

R. Pittman No. This process is an automatic process and the folks who
used to be WebMD who are, I guess, now Emdion, will assist with the
process. The TrOOP facilitator was gone ahead and awarded by CMS and
that's all taken care of. It won't show to you, but, basically, you'll
send your claims just like you have through WebMD and it will go ahead
and be processed by the TrOOP facilitator.

T. Jones So, there will not be any cost to the site then for
transactions, or will that be in the payment?

R. Pittman There will basically be no cost to you for the TrOOP
facilitator. There will be an added cost for this identification process
where we're going out and identifying patient eligibility because we
want to find out information such as is Joe Smith signed up with a plan?
If so, what is the plan? And we want to find out, if we're going to try
to bill this person's medication electronically, is this going to be
accepted or rejected? And, if it's going to be rejected, why and how can
we go ahead and fix that right at that point to make sure that it's
processed appropriately? And that's going to be the \$0.015 per
transaction.

T. Jones Okay. Great. And I have one other question. Earlier, you had
talked about those that had been auto-enrolled. And, earlier, Travis
Watts, we had talked with Jennifer, I guess, Stansbury, I think, from
CMS and she was in the process of getting with CMS and providing some
sort of listing to the tribes. Do you have any update on that?

R. Pittman We are in the process of looking at a data match to see if we
can go ahead and identify the dual eligible. Elmer Brewster is working
with the folks at CMS on this process and we hope to be able to get some
information out to the tribes shortly. It's just a matter of how we can
get the data systems matched.

T. Jones Okay.

Coordinator Next question is from Carol Goodin, Feather River Tribal
Health. Your line is open.

C. Goodin Yes. We're not clear here, if a tribe pays for the deductible,
does that count towards the patient's TrOOP?

R. Pittman The medications that are prescribed to a patient and given to
a patient from an HIS tribal urban facility will count towards the
deductible, but they will not count against the true out-of-pocket costs
or the TrOOP costs. So, while the medications you dispense will count
towards the deductible so that you can start billing after that amount
and that amount, of course, is \$50 for those with extra help and \$250
for those without any extra help, but it will not count towards the true
out-of-pocket costs.

C. Goodin Thank you.

Coordinator The next question is from Cynthia Larsen, Billings Area
Office. Your line is open.

C. Larsen Hello. In reference to the billing point of sale, isn't this
going to work just like point of sale works now where we have the format
set up for each one of these plans; it goes through WebMD or their new
name, whatever it is; and then, they're our clearinghouse and they
process that out to the individual PDPs; and then, the PDPs are actually
the ones providing the TrOOP with the information? Is that correct?

R. Pittman That is correct and it's detailed in a document that will be
posted tomorrow on the Web site and went out to all of your pharmacies
today. But, basically, you're absolutely correct. From the way you're
going to see it, it basically will be the exact same process you're
using. It's an internal process between the plans and the TrOOP
facilitator that will them to identify the true out-of-pocket costs.

C. Larsen Okay. With the addition of having the capability of doing the
270, 271 or the eligibility inquiry and response in the POS system.

R. Pittman That is correct.

C. Larsen And that too will go through WebMD who then goes out and asks
the individual PDPs for eligibility information.

R. Pittman That is correct. We'll continue to use WebMD and they'll have
that added feature.

C. Larsen I don't know how they're going to charge it though, the cost
for that inquiry, unless it's on an invoice from WebMD because it can't
really come from the plan's payment because there may not be a payment.

R. Pittman It will come from WebMD. They will charge you your normal
transaction charge, your regular switching fee, which is \$0.025 per
transaction and they will add on that \$0.015 for a total charge of
\$0.04 per transaction.

C. Larsen Okay. Thank you.

Coordinator Next question is from Janet Jennings, Sault Tribe Center.
Your line is open.

J. Jennings Yes. We had a question. Our pharmacy utilizes QS1 for
billing and how would that work with transferring over to RPMS?

R. Pittman I guess that depends upon is your pharmacy looking to come
back to RPMS? If they're looking to transfer back to the point of sale
package with PRPMS, they need to go ahead and contact Pam Switzer. If
they want to continue to use the other billing package, then they'll
need to contact the plans that you're interested in and go ahead and get
from them the information on how to set up the formats to go ahead and
bill, which they're probably already very used to because they use it
for all their other contracts. So, it's just a matter of are they coming
back to RPMS or are they continuing to use an outside billing package?

J. Jennings We'll be continuing to use QS1, but how would that transfer
to the billing side for TrOOP expenses then?

R. Pittman Well, in your current package you're using a switch entity
like WebMD and that entity will go ahead and be the person or entity
that contacts and goes through the plans and the TrOOP facilitator.
You'll need to talk to your switch to see how they're going to process
that and if there is an additional fee with that. If you're using WebMD
or now Emdion, then you can go ahead and contact them and they're very
familiar with the process and can go ahead and tell you how that's going
to be done and what additional charges you might face.

J. Jennings Thank you.

Coordinator Next question is from Lovetta Whitemouse, Fort Thompson
Indian Health Center. Your line is open.

L. Whitemouse Hello. One of our dual-enrollee patients came in and they
brought us an enrollment letter from the Silver Script, which is a
company of Caremark. Do we have an IHS agreement with that company? Yes,
that's the question.

R. Pittman One, I would be surprised if your beneficiary brought you in
a letter from a particular PDP. Hopefully, what they brought you in was
the yellow letter from CMS informing you that they had been assigned to
Silver Script by CMS, unless they take any action because I don't
believe the plans have been notified yet of the enrollees for the plan
or asked to correspond directly with the enrollees at this point.

But, be that as it may, we do have an agreement with Caremark and we
will identify on the Web site, again, it should be up tomorrow, which of
the plans under that agreement are identified. So, you should be able to
see that information tomorrow.

L. Whitemouse Okay. Well, he did get another letter too from the Silver
Script place on October 26^th^ and in this letter, it says that they
received notification from CMS that this person has been enrolled in
their prescription drug plan.

Roger This is Roger. I'm surprised at that too and I'll follow up on
that.

L. Whitehouse Okay. Thank you.

Coordinator The next question is from Lisa Mays, Jemez Health Center.
Your line is open.

L. Mays Yes. You lost me a little bit when you were talking about the
reimbursable expenses for tribes that decide to cover some patient
expenses. I was wondering if you could clarify what is reimbursable and
what's not for tribes that choose to cover some patient expenses.

R. Pittman Absolutely. Of course, there are a variety of different
situations, depending upon whether the individual is eligible for extra
help or not eligible for extra help. If we assume that you have an
individual that uses a large quantity of pharmaceuticals, say a patient
who uses \$3,000 worth of drugs a year, for that individual, should the
tribe decide to go ahead and pick up the premium costs for the
individual, the premium costs would be somewhere around \$200 to \$400,
depending upon the plan that the individual is enrolled in and that the
patient is part of.

> And, basically, for that particular individual, since they have no
> extra help, there would be a \$250 deductible. So, the first \$250
> worth of medications you dispense will not be reimbursed and there is
> a 25% co-insurance. For every prescription dispensed, the patient or,
> in this case, the tribe absorbs 25% of the cost and the plan will
> reimburse your for 75%. So, basically, on the first \$2,250, before
> you reach the coverage gap or the donut hole, as it's sometimes
> referred to, basically, the first \$250 of medications you're going to
> absorb and you're not going to get any reimbursement. In the next
> \$2,000, you're going to get \$1,500 worth of reimbursement and you're
> going to absorb \$500 or the 25% co-insurance.
>
> So, up to \$2,250, you're going to generate \$1,500 in new revenue and
> what it's going to cost you is since you normally would give the
> patient the medication anyway, what it's really going to cost you is
> it's going to cost you the premium cost and that's the \$200 to \$400
> you're paying in premiums. So, you pay \$200 to \$400 to a plan and
> you get back \$1,500.
>
> Now, the next decision is does the tribe, through a charitable
> organization, want to pay for the donut hole or the coverage gap? If
> the coverage gap goes from \$2,250 to \$5,100, so, if a patient used
> substantially more than \$5,100 worth of drugs in a year, the tribe
> may want to consider paying for that coverage gap. A charitable
> organization pays for those costs and once the person is through that
> coverage gap, then you can bill at catastrophic reimbursement rates
> and get 95% of the cost of the drugs reimbursed.
>
> So, if you had a patient with a condition that say was using \$12,000
> or \$15,000 or \$20,000 worth of drugs, it may very well be quite
> economical to pay the cost between \$2,250 and \$5,100 and then
> collect another \$5,000 or \$10,000 worth of revenue in the
> reimbursement during the catastrophic phase. But that will be one of
> those things that the tribes are going to have to look at on a
> case-by-case basis.
>
> For the individual patient there is no change. They're getting the
> drugs just like they normally would. It's just a matter of do you sign
> them up for Medicare Part D? Do you pay the premiums for them and do
> you track their expenses and pay through coverage gap to make sure you
> can get reimbursed for most of those costs?

L. Mays Okay. And my second question I had was who is the TrOOP
facilitator? Who do they belong to? Does each PDP have their own?

R. Pittman No. The TrOOP facilitator is NDC Health and that contract was
led by CMS and they are the TrOOP facilitator for everybody.

L. Mays Okay. Thank you.

Coordinator The next question is from Kris Locke of TTAG. Your line is
open.

K. Locke This is good timing for this question. Here's my question, if,
in fact, the tribe is able to set up the structure to be able to pay an
individual's TrOOP, what do they need to do to be sure that that is
currently attributed to the patient's TrOOP knowing that in other
situations, for example, for HIS facilities, that would not be
attributable to the TrOOP?

R. Pittman Certainly. That's going to be a difficult question. We're
working on those issues right now with the individual payers. We face a
difficult position with true out-of-pocket costs. Right now, if you were
in the private sector, the assumption of the TrOOP facilitator is that
if the plan tells you there is a \$5.00 co-pay, the assumption is that
you've paid that \$5.00 co-pay and that that \$5.00 can then go towards
the true out-of-pocket costs.

In our case, our patients, they are not paying the co-pay and that is
being absorbed by the IHS or tribal site and, therefore, we are
identifying to the plan and the TrOOP facilitator that the co-pay is not
to be processed as a true out-of-pocket cost. However, we will have some
beneficiaries who the co-pay or the co-insurance or the TrOOP costs
through the coverage gap will be paid by some entity, perhaps through a
charitable organization from the tribe, and we need a way to identify to
the plan and to the TrOOP facilitator that those were really costs that
were incurred and could be accredited or a credible to the TrOOP costs.

> So, we are still working on that process with the plan for some way
> for us to identify when that cost was paid and when it was not. But we
> do not have that in place yet, but, hopefully, we will have it in
> place before January 1^st^.

K. Locke So, will this have to be negotiated and clarified then with
each of the PDPs?

R. Pittman Yes, it will.

K. Locke Thanks.

Coordinator The next question is from Carol Goodin, Feather River Tribal
Health. Your line is open.

Sharon It's actually Sharon, but I'm here with Carol. I have a couple of
questions. One is I haven't heard anybody talk about if a client has a
change in their status, let's say they are Medicare only at this point
and become, after the first of the year, dual-eligible. How does that
work? How are they notified? How does it change their coverage and are
they able to change their plan at that point?

My second question is it hasn't been addressed to those who will age
into Medicare after the first of the year, do they get notification as
their birthdays are coming up and they're becoming eligible? What will
be the process?

And then, my last question has to do with the out-of-pocket costs and
tracking that. Am I clear that the tracking will be done by this MDC
Health for everyone so that at some point we would know we have clients
who will use \$1,000 to \$2,000 a month and in three to five months will
have met that maximum of \$5,100? Thank you.

R. Pittman You want to try any of those, Roger?

Roger Well, I could certainly try the first one, Robert, and that is,
yes, as people age into the program, they'll receive notices similar to
the ones that people are going to be receiving now during this initial
enrollment period. In fact, they'll receive the very same kind of
notice. I might just sort of generally mention about those notices I'll
send over to Captain Pittman for posting on your site our guidance to
the PDPs that have all the model enrollment letters and forms that they
would send out so that people can have a chance to take a look at all
those things. There are probably 25 exhibits that show all the kinds of
model notices that people will be able to use.

Let me turn, then, a little bit to I think it was the first question,
which had to do with changes in your circumstance during the year. In
that case, sure, if someone becomes Medicaid eligible say during the
year, remember that they'll be Medicaid eligible for services other than
just the drug benefit. When they become eligible for that, you obviously
will be able to bill the state Medicaid program for those services as
well and at that point in time, that individual would be notified that
they would be eligible for Medicare's Part D through that mechanism.

Robert, I know you've been addressing questions surrounding the
out-of-pocket cost issue and I don't want to confuse matters with my
comments on that.

R. Pittman Certainly. One other brief comment, obviously, the enrollment
period for folks who become eligible after this initial six-month period
between November 15^th^ and May 15^th^, say a person turns 65 in
November, they basically have a seven-month window to enroll in a plan.
They have the three months before they're eligible for Medicare, the
month they're eligible for Medicare, and the three months after they're
eligible for Medicare and they'll get notice way early to let them know
that this is their window to go ahead and enroll in the plan. If, for
some reason, they don't, then they'll have the annual enrollment period
at the last half of November and December to go ahead and enroll. So,
there will be ample opportunity and ample time for folks to enroll and
they will get notification on that.

The other half of your question that really wasn't asked was if you have
a patient who is dual-eligible, Medicare and Medicaid, and for some
reason then gets off Medicaid, basically, they're going to be considered
to be a dual-eligible for the entire year period. So, they are basically
set, so once they get into Medicaid, they're set for the remainder of
that calendar year. Whether they come in to Medicaid or whether they
leave, they're considered a dual-eligible and CMS will be notified as
they enter and leave Medicaid so that they will go ahead and put them in
the correct category.

I apologize. I need you to ask the final question again.

Sharon It was regarding the tracking of when they're reached their
out-of-pocket, the donut hole, or the coverage gap. Some of our patients
will reach that in a short amount of time. Is that the MDC that's
keeping track of that? And how will we know when they've reached that
point?

R. Pittman The plans are notified on a regular basis of where people.
The TrOOP facilitator lets the plans know at any given time in the
process and, basically, through either the electronic process or by
calling the plan's 1-800 number, we can identify at any time where the
beneficiary is in the reimbursement process. And if a beneficiary comes
up against the coverage gap and no one is going to pay for that coverage
gap, we will be notified so we will know to stop billing and no longer
submit claims that are going to be automatically rejected.

In the same way, if a patient, for some reason, purchases medications in
the private sector, if they are medications you don't carry, but they go
out and purchase them on their own, that will be the job of the plan to
add those costs in so the plan has that information and that information
is accessible to you so you know where exactly in the process the
patient is at any given time. Does that answer your question?

Sharon Yes, it goes. Thank you. And I did want to say that for a lot of
our members, I don't know if it's true for other facilities in
California, unfortunately, California calls Medicaid MediCal and that's
some confusion when our members have received the letter saying they
have Medicare and Medicaid dual-eligible. They're wanting to know what
that is, so we're just having to educate. It would be nice to have that
blurb somewhere, you know, Medicaid is MediCal in California. I know
it's a lot of extra work, but just an FYI.

R. Pittman Thank you. Next question.

Coordinator The next question is from Lisa Mays, Jemez Health Clinic.
Your line is open.

L. Mays Hello. Back to those who become duals after the auto-enrollment
deadline, do they have to apply for the extra help on their own and
enroll on their own? I'm assuming that you all have sort of a cut off
list of people who are to be auto-enrolled and then, whoever becomes
eligible for Medicaid after that will have to do what?

R. Pittman Well, they'll receive the same kind of notification that
individuals who are in the initial group of people to be auto-enrolled
will receive. So, you're talking about someone who becomes eligible,
say, for example, Medicaid eligible, dual-eligible in March of 2006.

L. Mays Right.

R. Pittman Well, that individual will receive the same sort of
notification that people have just received regarding their dual
eligibility status and they will be the same as and in the same
circumstance as those folks. If they are true dual-eligibles, they will
be auto-enrolled in a plan. Contrast that again with people who are
potentially eligible for extra help. Those people will, just as they do
now, have to apply for extra help. That is individuals who reach age 65
and/or at or below 150% of the poverty level, between a 100% and 150% of
the Federal poverty level, they would, as they do now, have to actively
apply for the extra help.

L. Mays Well, we were told that duals did not have to apply for the
extra help.

R. Pittman Duals will not have to apply for the extra help. They don't
have to apply now and they will not later.

L. Mays Okay. So, auto-enrollment will basically continue.

R. Pittman Correct. Auto-enrollment will continue on a rollover basis as
people either reach age 65 and are dually eligible at that point in time
or if somebody becomes eligible afterwards, they will also be
auto-enrolled.

L. Mays Okay. Thank you.

R. Pittman You're welcome.

Coordinator Next question is from Tracy Jones, Chickasaw Nations. Your
line is open.

T. Jones I don't know if this is so much a question to the group or
Robert for you to be thinking about or comment, but the closer this
thing gets and the more that we realize there's just an ongoing
maintenance of this program, are people voicing that they're hiring
additional staff to oversee this?

R. Pittman I think from discussions I've had with many of the different
service units staffing, obviously, is a great concern. This is a big
bowless of activity between now and probably the end of May or so, but,
as you mentioned, this is an ongoing activity, whether it be continuing
to enroll people who become Medicare-only eligible or who might be
eligible for extra help or who suddenly turn 65 and are dual-eligibles
that need to be switched, sending out credible coverage letters on an
annual basis. This is an ongoing activity that we're going to see into
the future and we need to make sure we have appropriate staffing to do
this.

Again, that falls to the individual site or the individual service unit
to make those decisions on how they can appropriately get staff to do
that and how they can allocate current staff to meet that need. But,
yes, we are hearing concerns from folks that they appreciate how much
time and effort it's going to take, especially with this initial
bowless, but also with the ongoing maintenance of the program.

T. Jones Okay. And we have one other question. First of all, on the
letters that the lady earlier was talking about that one of their
patients have received, we are seeing those same letters from our
patients, the same company, so I just wanted to throw that out there.

R. Pittman As we go on, as we get closer to November 15^th^, I would
expect that the companies will be notifying the patients.

Roger In fact, the companies are required to notify the patients.

T. Jones Well, I'm talking about that letter that you all were saying
you were surprised that they had gotten that.

Roger Right. I am surprised that they have sent it out this early, but
companies, in fact, will be required to notify patients. They'll have to
send them a notice and they'll have to send them a member card and all
the accompanying materials.

T. Jones And I'm a little confused, on the contracts, when we're filling
those out, there is getting a formulary that has like a formula there.
I'm a little confused on the right. I mean, we've just been accepting
those in the contracts as we do them. Is there a different way we should
be doing that, a different strategy to be looking at as far as right?

R. Pittman Well, each of the companies offers a different reimbursement
rate for pharmaceutical. I can't really recommend to you what you should
do as an entity. What I can tell you is kind of our philosophy as we
looked at the various agreements that were offered to us. For our folks,
obviously, our biggest concern is replacing the Medicaid dollars we're
losing when people switch from Medicaid to Medicare, our dual-eligibles.
Our initial philosophy was we wanted to get as close to a Medicaid-like
rate as we possibly could and when we received notification from the
various entities that they were offering an AWP minus some percentage
point plus a dispensing fee, we came back and talked with them and said,
"We would like to offer a counterproposal of," and we proposed whatever
the Medicaid-like rate was for that particular state that they were
dealing with.

And for a few companies that was fine. For other companies, we had to
talk about a lower reimbursement rate. We basically talked about going
down to AWP minus 25% plus a \$4 dispensing fee and we really looked
very hard at any contracts below that or a lower dispensing fee for a
30-day supply of drugs feeling that if we had good offers from other
companies, we probably wouldn't want to sign agreements for much lower
reimbursement rates.

For a lot of companies, the rate was very confusing. Most of them wanted
to offer a much lower dispensing fee, usually somewhere between \$1 and
\$2. The negative rate off the AWP was generally something fairly
reasonable for us, but the dispensing fee was very low. And the thing
that really got us and that most of the contracts were saying the AWP or
the max price. And for some entities they were using the CMS max price.
For other entities, it was an internal max price that they calculated
and just tell you what it is and, in many cases, it was AWP minus 55% or
more off. So, we basically came back and said we wanted to eliminate the
max price from all of our agreements. For those companies that couldn't
do that, we basically didn't sign agreements.

You have to make a decision as a tribal or urban program what you're
willing to get for reimbursement. I believe all the entities we talked
to, they basically said if you order a 90-day supply of drugs, we're
going to give you an AWP minus rate with no dispensing fee because
that's what we can get from the mail order program. So, we basically
couldn't get any latitude on 90-day dispensing fees, so we got a lot of
30-day dispensing fees.

So, you have to make a decision. Are you going to go with a group of
agreements that can give you the rates you want or are you going to just
sign for whatever you can get and hope to get more of your patients into
the higher paying agreements? Keep in mind that the reimbursement rate,
while an important component, isn't the only component of the agreement
to look at because there are other things in the agreement that a lot of
tribes have issues with.

> Some plans talked about waving of sovereign immunity. Some plans
> talked about liability insurance and other coverages and other costs
> that the tribes did not want to have to deal with. And, keep in mind,
> anything is negotiable. You just have to look through it and ask for
> things to be removed that you don't like. And if they do it that's
> fine. If they don't, it's a give and take to get the agreement that
> you want.
>
> Our hope is that over the next year or so the tribes and IHS can kind
> of get a better fee for what the companies are willing to offer. The
> companies will go back and look and see kind of what how they're
> reimbursement rates effected their profits and then, maybe, as we
> negotiate the agreements again next year, which we're going to have to
> do every year, we can maybe come to a more standardized agreement for
> HIS and the tribal entity. So, that's a long-winded answer. I hope
> that helps you.

T. Jones No. That was a wonderful, wonderful answer. Can I ask one more
question?

R. Pittman Certainly.

T. Jones In regards to the plans, of course, your first criteria is
what's best for your patient; secondly, what also works great for your
facility; but, then, thirdly, do you have any strategy for recommending
that we use as few of plans as possible or does it really matter as far
as managing your patients in the future and the hereafter? Is there any
strategy, I guess, on minimizing the number of plans that you deal with,
if you have the opportunity to do that?

R. Pittman I would imagine over time that we would probably be working
our way towards a handful of plans. Obviously, since we're just starting
to get a good look at the formularies of the plan, we may have many more
plans this year than we have in future years. But I would imagine that
over time we will probably be trying to get down to somewhere between
five and ten plans that can probably meet the needs of all of our
patients.

There will always be a need for more than one plan because a single plan
probably doesn't have a broad enough formulary to cover all of your
patients. But I would imagine that maybe with a mix of a couple of
regional plans and some national plans with good reimbursement rates and
good formularies you will find that the vast majority of your patients
probably end up going into a handful of plans.

T. Jones Is Part D going to be postponed?

R. Pittman I could let Roger answer that one, but from my point of view,
I would say no.

Roger From our point of view, no, as well.

T. Jones Okay. No more questions from Oklahoma.

R. Pittman This train has left the station. It will be sailing.

Coordinator The next question is from Cynthia Larsen, Billings Area
Office. Your line is open.

C. Larsen I have a further question back on those people that become
dual eligible after this initial enrollment period. Do you know what the
timeline will be that they'll be auto-enrolled? They'll receive the
letter saying that you're dual eligible, here's a plan for you. Is it
going to be within a month?

Roger This is Roger. You know, I am not sure and I will get the specific
answer to that for you. But I would think it would be coincidental with
the date that they become eligible for Medicaid. I think that, but I
will get the specific answer to that question for you, Cynthia.

C. Larsen Okay. And those too will still have the capability of changing
once a month.

Roger Absolutely.

C. Larsen Okay. My second is just kind of a comment. We were talking
about the resources and the positions and what it's going to take to
actually get this done. You know, just a comment. We've decided to do
the credible coverage letter from an area standpoint for the IHS
facilities sharing everything with the tribal facilities. And we put in
it's probably going to be 120 plus hours just getting the credible
coverage letter out. So, that's just a bit of information.

But, also, just to let you all know, through the assistance of Pam
Switzer, we're going to try to develop a position description that is
specific to point of sale and Medicare Part D. So, once I get that
available and through classification, we'd be more than willing to share
that with everyone.

R. Pittman Thank you.

Coordinator The next question is from Carol Fisher, Seneca Nation Health
Department. You line is open.

C. Fisher Good afternoon. Dr. Pittman, I'm directing this towards you.
Earlier, you talked about the extra help and I'm still a little confused
and maybe others are too. You mentioned that the premium could be paid
through tribal non-Federal funds and then, later, we talked about
setting up a charitable organization to cover the donut hole. How will
that work? I thought we were still waiting to hear from Congress.

R. Pittman Well, we're still waiting to hear from Congress on
legislation to allow us to use Federal funds to pay for premiums for
beneficiaries. Right now, there is no restriction on other folks paying
premiums for anybody. An individual or a family or a corporation could
pay premiums on anybody they like, as long as it's not IHS because IHS
does not have authority to use Federal funds to pay that premium. So, if
a tribe decides to pay premiums for select beneficiaries or all their
beneficiaries who are not eligible for dual-eligible or extra help below
135% of poverty, where the premium is taken care of, they could do that
now, as long as they're not using Federal funds.

The premiums don't count towards the true out-of-pocket cost, so that's
not generally an issue with the premiums. It's just a matter of who is
going to pay for them and how it's going to be paid. Now, for the true
out-of-pocket cost our understanding is that has to come from the
individual or someone on the individual's behalf or through a charitable
organization.

> We're still waiting for some final instructions from CMS on how tribes
> could form those charitable organizations and how exactly that money
> would have to be transferred back and forth to make it a true payment
> by that charitable entity and as soon as we get that information we
> will post it on our Web site, maybe even have another conference call
> with the tribal entities to go over that.
>
> But, ideally, right now what you'll be doing is identifying those high
> cost drug users who might potentially benefit from the tribe paying
> for the true out-of-pocket cost and, therefore, those would be the
> folks we would want to look at as soon as we have that information on
> how we can go ahead and pay for that true out-of-pocket cost.

C. Fisher I guess I have to ask the question can third-party payments be
used to pay this premium? Our influx of third-party payments, can that
be used toward paying premiums?

R. Pittman Our understanding is that your Medicare and Medicaid and
private insurance reimbursement could be used for premium costs.

C. Fisher Okay. I think you've answered my question. Thank you so
kindly.

Coordinator The next question is from Charla Carriere, Washoe Tribal
Health Clinic. Your line is open.

C. Carriere Yes. Just a few minutes ago they were mentioning about the
dual-eligibles being automatically assigned. I was under the impression
that they were going to be assigned a pharmaceutical company on January
1^st^, if one hadn't been chosen. And the way I understood it was one
person you had spoke with that, first, they were sent out a letter. If
they didn't respond to or do any action on the letter, then they were
going to be sent out an actual card showing who the pharmacy was that
was chosen for them, or did I misunderstand that?

Roger This is Roger. People who are dual-eligibles should have already
received a letter, that's that yellow letter, indicating which plan that
they'll be auto-enrolled into if they take no further action. And that
auto-enrollment will be effective on January 1^st^, 2006. Some people
were reporting that they had seen letters that some of the plans into
which people were auto-enrolled had already begun to send letters to
individuals telling them that they were auto-enrolled in that plan, as
well, as a follow-up to the letter that they received from CMS. So, some
people, it appears, may have received letters from both CMS and from the
plan itself.

I now understand and during our call here I checked with our PDP
enrollment people that in fact the plans can begin to send out those
letters. So, I would expect over the next several weeks that you may
start to see people getting letters from the plan and those letters
will, in fact, tell people that they'll be enrolled in those plans. And
then people will receive from the plans a member card and other
information from the plans about how to access the benefits through the
plans.

C. Carriere I'm glad you told me that because then that's why we haven't
had any response. None of our patients have called back regarding that
letter. I think we've gotten one.

Roger No. That's because many of the plans probably have not sent that
letter themselves yet. That's different than the letter that they should
have gotten from CMS. That's the yellow letter. That's a letter from us,
from the government, telling they'll be auto-enrolled into a particular
PDP. Then, that PDP, that prescription drug plan, will send a separate
letter of its own on its own letterhead to them telling them that
they'll be enrolled in their plan.

C. Carriere Well, that's what I'm saying is that's why we haven't had
response because they're under the impression, well, Medicaid's not
going to pay, or MediCal, therefore, we're already enrolled. We don't
have to worry about it. So, we've had no response. So, evidently, we're
going to have to write a letter. I'm glad we talked because our letter
that we were going to send out as a follow-up was not going to be the
same. We'll let them know that they need to come in and choose a plan
that actually we're contracted with because we'd have to be contracted
with who they've chosen.

Roger Exactly. That's what Captain Pittman was saying before.

C. Carriere That concerns me.

Roger That's a major concern for you that you help them or work with
them to choose a plan that meets their needs, but also that, hopefully,
works with you as well.

C. Carriere Exactly. And that's what we were talking about today because
we didn't know that the yellow letter stated necessarily that they were
going to be auto-enrolled because the patients say, "Okay. Great. I'm
auto-enrolled. No problem."

Roger They'll be auto-enrolled into a particular prescription drug plan
and it would be wonderful for you to, as Captain Pittman stated, to
bring those people in and chat with them about what their status is so
that you can help work with them to make sure that they're enrolled in a
plan that meets their needs and that you can work with as well.

C. Carrier Well, do you know what I wanted to tell them too? If you go
online, people were talking about the formulary, I sent out online with
a CMS and our pharmacy gave us the drugs that they use that are the most
expensive for end-stage renal disease and different drugs. And it does
bring up categories of the insurance companies that actually cover those
drugs and I'm kind of going through it so I can get a feel of who all
covers the major drugs that are most expensive. And it's kind of
enlightening, so you could certainly utilize that in making decisions
and choosing the insurance company for some of these patients.

R. Pittman Certainly. If folks have not mailed out a letter yet to their
dual-eligibles informing them that they're going to be getting that
yellow letter from CMS, you can look on the pharmacyissues.ihs.gov Web
site for the ... letter that will basically tell your beneficiary that
they're going to get this letter or will have already gotten this letter
and to bring it in and talk with you.

Additionally, if you're not getting a bunch of response from your
beneficiary, towards the end of the month, you'll be able to go to the
plan finder and plug in the patient's name and Medicare number and see
which plan they're enrolled in. And that way you will be able to
identify that if the patient is already in a plan you have an agreement
with, then you're all set. And, if not, you need to talk with them and
perhaps bring them in and see about getting a different plan.

C. Carriere Now, you said that's plan finder. Is that going to be under
pharmacyissues.ihs.gov?

R. Pittman The dual-eligible letter will be under the
pharmacyissues.ihs.gov. The plan finder is on the CMS Web site at
[www.medicare.gov](http://www.medicare.gov/).

C. Carriere You know, I just went online a few minutes ago to try to get
on [www.pharmacyissues.ihs.gov](http://www.pharmacyissues.ihs.gov/). It
showed that the page couldn't be revealed. It's
[www.p-h-a-r-m-a-cyissues](http://www.p-h-a-r-m-a-cyissues/), all
together. Is it issue or issues?

R. Pittman Issues with an "s."

C. Carriere Okay. Then, dot ihs or not?

R. Pittman Dot ihs dot gov. Our folks in information technology may have
been loading up some of the things I sent them today, so it may be down
for just a brief period. I would try again later.

C. Carriere Okay. Thanks so much.

R. Pittman We've reached 5:00, so we'll go ahead and see if there is one
more question and then we will go ahead and wrap up for the conference
call. Is there another question, operator?

Coordinator At this time, there are no further questions.

R. Pittman Operator, can you tell me how many folks we had on the call?

Coordinator Yes. One moment. It looks like about 127.

R. Pittman Thank you. Roger, do you have any final comments before we
log off?

Roger Thank you, Robert. Just very quickly I'd like to remind everybody
that we are planning to have a Webcast tomorrow on the use of the plan
finder and I'd strongly suggest that if people have a chance take a look
at cms.hhs.gov and look under the training link and that will tell you
how to reach that Webcast. And there is also a demonstration tool for it
right now. That's it. Thank you.

R. Pittman And we will also blast that out via e-mail through our area
coordinators and to our pharmacy staff. I want to thank you all for
joining us on this fourth call trying to educate folks on Medicare
prescription drug coverage and please, if you have any additional
questions that you did not get to ask today, e-mail me at
<robert.pittman@ihs.gov> and we will go ahead and get those Q&A's out.
We will be posting this entire conference call on the
pharmacyissues.ihs.gov Web site. It should be up within a week or so.
Please take a look at that and, again, if you have any questions, let us
know and thank you for attending today.

Coordinator Thank you. At this time, the call has ended. Please
disconnect. Thank you for attending.