Medicare Part D prescription plans are required to give patients 60 days notice before changing the status of a medication covered under the plan, according to Jeffrey Kelman, M.D., medical officer for CMS' Center for Beneficiary Choices. Kelman notes that Medicare Part D prescription plans can change their formularies by dropping covered medications or boosting them to higher cost tiers. However, doing so requires CMS approval and a 60-day notice to patients before the medicine's status changes.
"A plan can add or lower the cost of a drug simply by notifying CMS," said Kelman. "But if the plan drops or changes its tier, it must apply to CMS for approval first. And it must give the beneficiary a 60-day notice."
That, he said, should enable physicians to write new prescriptions, wean patients from the original medication and begin them on a substitute drug to continue treatment.
Moreover, Medicare will waive the quarterly time limit on reimbursing for lab work when a patient must change medications; CMS will pay physicians for follow-up lab panels and office visits prompted by formulary changes, said Barbara Cebuhar, a spokesperson from CMS.
That's good news for family physicians, who have pointed out that Medicare generally limits payment for lab panels to once per quarter. That limit could pose a quality-of-care problem if a prescription change occurred in the middle of the quarter. Under previous rules, Medicare would deny payment for lab work required to monitor for potentially serious side effects within one month of a medication change.
However, patients -- not physicians -- most likely will be required to file appeals when a plan drops medications required by a patient who cannot tolerate or who fails to respond to generic or substitute medications, according to William Rogers, M.D., medical director of the CMS Physician Regulatory Issues Team.
The appeals issue presents some challenges, said AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif.
"After a patient chooses a plan, he's locked into it for a year, even if the plan changes its formulary" and drops the patient's long-term medication, she said during a 2005 AAFP State Legislative Conference session on Medicare Part D.
Few elderly patients have the wherewithal to complete such paperwork and follow through on the appeals process, said Frank, adding that the responsibility likely will fall to the physician.
"Now, in addition to filing appeals for patients when private insurance changes its formularies, we will have to appeal for Medicare patients," she said.
A Nov. 10 survey by the Kaiser Family Foundation and Harvard School of Public Health (PDF file: 28 pages / 135 KB. More about PDFs.) found 32 percent of respondents said they would consult their physician for help selecting a prescription drug plan under the program. Survey respondents also trust their physicians to have that information: 53 percent said physicians were "very" or "somewhat" likely to spend time helping patients choose a drug plan, and 65 percent said they expected their physicians to be very or somewhat knowledgeable about patients' drug plan choices.
In addition to providing information about the new prescription drug program on AAFP's Medicare Part D Web page, the Academy is working with Medicare Rx Education Network to provide resources physicians can use when counseling patients.
