|
E-mail this page to a friend!
Medicare Says Drug Plan 'Transition' Not Over for
Those Not Through with Process
Issues fact sheet
outlining their actions toward smooth transition
March 31, 2006 – Medicare today acknowledged the
end of the "transition period" for the Medicare drug program but issued
a fact sheet saying the requirement that prescription drug plans have
"an effective transition process is permanent." The statement said the
transition requirement continues to apply for beneficiaries who did not
complete the transition process. It may offer little comfort, however,
to those who are calling for the transition period to be extended.
| |
Related Stories |
|
| |
Guarantee of Drugs Ends Today for Medicare Drug
Plans
Many worry some
senior citizens will not be able to get needed drugs
March 31, 2006 – The extended transitional period
for the Medicare drug program – a time during which the insurance plans
agreed to cover all necessary drugs for enrollees – ends today and some
are predicting serious problems ahead for beneficiaries and are pressing
Medicare for another extension.
Read
more...
Seniors Who Conquer the Challenge are Satisfied with
Medicare Drug Plan
Problems found in those who lack the energy or do
not understand English
March 27, 2006 – Senior citizens who take the time,
often with help, to walk through the decisions required to chose a
Medicare drug plan are satisfied with the program, according to an
in-depth look at how Americans are accepting the new Medicare Part D by
the New York Times.
Read
more...
Medicare Drug Program Now Covering Over 27 Million
as Enrollment Jumps
Good progress made in last few weeks with 2 million
more covered
By Tucker Sutherland, editor
March 24, 2006 – Comparing the numbers released
yesterday by Medicare on enrollment in the drug plan with those released
last month do not exactly match with the news release accompanying the
numbers, but anyway you look at the numbers the indicate good progress
over the last few weeks. Although, some estimates say as many as 16
million seniors and others eligible are still not covered by a drug
plan.
Read more...
Low-Income Senior Citizens Say No Problems Using
Medicare Drug Benefit
Survey for insurers says the drug plans are serving
the poorest seniors well
March 13, 2006 - Nine out of 10 seniors who are
dually eligible for Medicare and Medicaid – the "dual eligibles" - say
they have experienced no problems using the new Medicare drug benefit, a
new survey released today by the association for the insurers has found.
Read
more...
>
Studies Show Medicare Drug Plans Offer Significant
Discounts and Savings
>
Officials Confirm Medicare Will Have Fewer Drug
Plans in 2007 Read more
on
Medicare Drug Program |
|
"Medicare’s highest priority is making sure that
Part D beneficiaries have access to the drugs they need. Millions of
prescriptions are being filled every day, with Medicare drug plans
generally covering a broader range of drugs than many public and private
health insurance plans," according to the fact sheet.
Following is the rest of the Medicare Fact Sheet:
Just like any other insurance plan, Medicare drug
plans have preferred drugs and prior authorization requirements to
promote safe and effective drug use and to avoid unnecessary costs. To
help ensure smooth transitions to drugs that are covered, and to allow
beneficiaries time to obtain exceptions to these requirements when
clinically appropriate, Medicare called on plans to implement a
three-month initial transitional period for Medicare prescription drug
coverage.
While that transition period is ending, Medicare’s
requirement that prescription drug plans have an effective transition
process is permanent.
This requirement continues to apply for
beneficiaries who did not complete the transition process during the
90-day transition period.
First and foremost, at all times, Part D plans have
an important role in communicating with their enrollees and informing
them about what they need to do to make a successful transition. They
also need to make timely decisions on enrollees’ requests for exceptions
and appeals.
Medicare Part D enrollees should not have to learn
at the pharmacy counter about their need to obtain prior authorization
for a drug or transition to a different drug, nor should they face
delays at the pharmacy counter because exceptions requests have not been
resolved.
Throughout the transition period, CMS has
repeatedly corresponded with plans outlining their role in assisting
beneficiaries in this transition. These communications include:
★
Transition Policy Reminder (January 6).
CMS informed prescription drug plans that delaying or denying
initial prescriptions for new enrollees at the pharmacy counter with
prior authorization or step edit requirements is not consistent with
CMS’s transition policy.
★
Further Transition Policy Reminder (January 13).
CMS clarified our guidance and told plans that they need to have a
process that ensures that “first fill” prescriptions are filled
promptly.
★
Collaborative Next Steps (January 18).
CMS asked plans to provide beneficiaries with a temporary supply of
medically necessary, non-formulary medication in order to smooth the
transition process. We also pointed out that plans should use sound
judgment to extend coverage in special situations where a longer
transition may be required for medical reasons.
★
Transition Extension (February 2).
CMS called for an across-the-board extension of this temporary
supply until March 31 for individuals enrolled during the first three
months of the program.
★
Transition Next Steps (March 17).
CMS reminded plans that the purpose of the required transition
process is not simply to provide a temporary supply of non-formulary
drugs, but to provide enrollees with sufficient time and guidance to
work with their heath care providers to switch to a therapeutically
appropriate formulary alternative, or to request a formulary exception
if medically necessary.
★
Critical Next Steps as Transition Period Ends (March 29).
CMS reiterated that plans should provide enrollees who have used a
transition benefit with the appropriate assistance to help them
successfully transition to a formulary drug or take the necessary action
to maintain their current medication.
CMS made it clear that it is holding plans
accountable for meeting their contractual requirements for resolving
exceptions and appeals. CMS is monitoring plan performance and expects
them to provide a temporary prescription drug supply when they are
unable to meet established timeframes. In addition, CMS will impose
corrective action, and where necessary employ stronger
sanctions—including civil monetary penalties—when enrollees are unable
to obtain the drugs they need on a timely basis.
Approaches plans can take to help enrollees
understand what they need to do to successfully transition to Part D
coverage include:
● Analyzing claims data to determine which
enrollees needed additional information;
● Contacting enrollees to ensure they have the
information they need to enable them to switch to an on-formulary drug,
or whether they need to get a prior authorization from their doctor or
file a formulary exception request;
● Increasing staff, call center, and pharmacy
line capacity to respond to an anticipated increase in the volume of
exceptions requests; and,
● Extending the transition period, on a
case-by-case basis, if the enrollee’s exception request or appeal has
not been processed by the end of the transition period.
CMS has also taken additional steps to assist
physicians, pharmacists and other health care professionals assure a
smooth transition.
For physicians and other health care providers:
● CMS has an extensive outreach program to health
care providers to inform them of the resources available to them to help
their patients through this transition period.
● CMS offered a formulary finder on its website
to enable providers to find plans in their states matching the patient’s
required drug list. In addition we worked with Epocrates, the medical
software company, to make formulary and other coverage information
available to providers.
● CMS distributed and posted a “Transition
Toolkit,” including information about exceptions and appeals and other
elements of a smooth transition, to providers.
● CMS has provided links to plan formulary and
coverage information.
● CMS has supported the work of health plans,
physician groups, and other stakeholders to develop a consistent form
for straightforward processing of formulary exception requests, as well
as for common prior authorization requests.
For pharmacists:
● CMS communicated extensively with chain,
independent and LTC pharmacies to make sure they were informed about
transition issues and able, when called on, to assist their customers
with Part D prescription coverage.
Issues of Medicare Rx Update with specific
information about the transition process have reached pharmacists eight
times since December, and we have held special “Open Door Forum”
sessions during the transition period to provide pharmacy-specific
information on the transition and to enable pharmacists to call in and
speak directly to CMS staff.
● CMS has supported the work of health plans and
pharmacy groups to develop consistent codes and responses for pharmacy
billing systems, to significantly reduce the time and usual
administrative costs faced by pharmacists in dealing with a range of
health plans. In particular, the codes will provide consistent messages
to the pharmacist on such issues as off-formulary drugs, prior
authorization, quantity limits, and drugs not covered under Part D.
● CMS required pharmacists to post the Model
Pharmacy Notice, which outlines the beneficiary’s rights to exceptions
and appeals.
Click here to Search SeniorJournal.com for more on
this subject
Click to More Senior News on the
Front Page
Copyright: SeniorJournal.com |
