Moving Forward on Part D: CMS Is Working to Smooth Out the New Wrinkles

Internal Medicine World ReportMarch 2006
Volume 0
Issue 0

Rogers Is the Director of the Physician Regulatory Issues Team, Centers for Medicare & Medicaid Services.

As you know, the Centers for Medicare & Medicaid Services (CMS) has launched the biggest federal health care program since the original Medicare program was created in 1965. Over the next 10 years, this $720-billion program will be open to the 43 million people who ?currently qualify for Medicare benefits.

As required by the law that created the benefit, pharmacists started to fill prescriptions before the sun rose January 1, 2006. In fact, Part D beneficiaries filled 6.5 million prescriptions in the first 10 days of January. Barely 60 days into the program, more than 25 million Medicare recipients are covered?a number that is well on track toward the goal of 28 million to 30 million enrollees in the first year.

Addressing the New Challenges

It has not been easy or worked smoothly in every case for patients or physicians, but we are working hard to streamline the process and address the new challenges that have received wide coverage in the media. As a physician, you likely have been, and know patients who have been, affected by some of the issues that resulted from this huge undertaking.

Keep in mind that even in those first few days of Medicare beneficiaries without paperwork and overworked pharmacists, the vast majority of patients did get their medicines.

We are currently working on parts of the program that physicians and medical organizations find challenging. We have weekly national provider conference calls and are continuing to work with the American Medical Association and specialty societies that have given us a short list of issues, including:

? Prior drug approvals and ex?cep?tions are burdensome. We need to minimize the number of drugs that are subject to prior approvals and make the process more efficient.

? Multiple formularies are hard to keep straight. Multiple formularies?plan-specific and drug-specific?add to the complexity and are another administrative burden for those who prescribe the drugs.

Let us look at each problem and some of the solutions.

Health spending and drug tiers

We want to make sure that every Medicare enrollee gets the right prescription at the lowest cost possible. The prescription drug plans have a key role in this process. Drug spending has been in?creasing at a rate of 13% to 14% annually (Figure). Drug tiers and prior ap?p?r?o?v??als have been effective?albeit challenging?tools to limit unnecessary or inappropriate prescribing and health expenditures.

For this reason, previous prescription approvals and drug tiers are not going to disappear. However, we discovered that in Medi?care's case, a large percentage of the drug tiers were imposed because of plans' concerns that they were inadvertently paying for a drug that should have been paid for by Part B of the Medicare plan.

We have, therefore, taken steps to eliminate these particular previous ap?provals. The previous approval for a $3 prescription for prednisone, for example, should soon be a thing of the past. When the US Congress created the benefit, the goal was to have at least 2 competing prescription drug plans in every state, but the market far exceeded our expectations. And the fact that Medicare beneficiaries can choose a plan that meets their individual needs is a significant benefit.

Multiple formularies

There will also be some consolidation of drug plans in the next couple of years, as plans that are not as competitive will be dropped out of the program. For the moment, we must adapt to multiple plans, which also means multiple formularies.

Multiple formularies are hard to keep straight. The simplest way to make sure your prescribing patterns comply as much as possible with the patient's formulary is by using the free software from Epo?crates ( This software can be loaded into a personal digital assistant or used on an Internet-connected desktop. This will provide you with the formulary information for a drug you select, as well as other recommended drugs that are preferred in that particular formulary. We are working with Epocrates to make this tool even more useful for physicians in the future.

You may have some questions when you or your staff need to help a patient who is filing a previous authorization for a medication or when asking for an exception to a medication's tier.

You can find all the exceptions, appeals, and pharmacy numbers for any specific plan throughout the country at Scroll down to the Part D tools to find each plan's contact numbers.

We have also assembled some of the most important tools for your office's use on this Web site, which will help make accessing the right person at the right time easier.

Prior approvals and exceptions

We are working to expand the use of a standard form to request a prior approval or exception to eliminate the frustration of tracking down the appropriate form. But some drugs still require a drug-specific, disease-specific form to collect the clinical information necessary to justify the prescription.

CMS is working to aggregate all the special forms so that office staff can print a form for the physician, nurse practitioner, or physician assistant. Once completed, you will be able to fax any of these forms directly to the plan, which will expedite the process and avoid a time-consuming phone call.

Extended Deadline

Part D transition drug coverage is now extended to March 31, 2006, for those individuals who were enrolled in the first few months of the program.

This extra time will help Medicare recipients arrange for an alternative medication or allow them to file an exception so that they can continue their current drug if needed.

Even after this extension expires, newly enrolled individuals are always entitled to at least a 30-day transitional supply of nonformulary drugs.

In addition, a point-of-sale option is available that allows those who are eligible for Medicare and Medicaid to join a plan at the pharmacy counter, so they can get the drugs they need.

Examples of some common situations are available at

Let Us Know How We Can Help

There are many other ways that CMS can reduce the administrative burden that Part D has presented to your practice. We are interested in hearing from you.

You are also welcome to join our providers' conference call every Tuesday at 2:00 pm Eastern time. The phone number is 800-619-2457, and the pass code is RBDML. Send us any provider issues by e-mail to

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