Medicare Part D Confusion Must End in 2007, CMS Tells Plans

By News Staff
4/12/2006

Working with Medicare Part D prescription drug plans, or PDPs, should get easier for physicians next year as a result of instructions recently sent to insurers by CMS. The instructions are part of a "call letter" that describes the parameters Part D plans must meet to participate in Medicare Part D next year.

To participate, PDPs must offer a "one-stop" area on their Web sites for physicians who need information, forms and contact information when seeking prior authorizations or making appeals to plan formularies, according to the CMS bidding instructions for 2007.

"PDP sponsors are expected to limit administrative burdens for physicians and other providers by implementing recommended best practices for consistent forms, including initial triggers for formulary exceptions and processes for providing needed clinical information for processing prior authorization requests for specialized drugs," the CMS call letter says.

In addition, plans must

develop and maintain information systems that accurately process updated enrollment information at least weekly;
verify enrollment and copayment status of automatically enrolled dual eligible beneficiaries at least biweekly;
answer 80 percent of incoming calls from physicians, pharmacies and the public within 30 seconds and limit abandonment rate of all incoming calls -- in which the caller hangs up after being put on hold -- to no more than 5 percent;
follow CMS transition guidance in allowing a temporary supply of nonformulary drugs for at least 30 days in the retail setting;
explain to enrollees that the transition supply of the nonformulary medication is temporary and that enrollees must work with their physicians to identify appropriate alternative drugs or seek an exception; and
offer no more than two Part D options "unless one of the bids is an enhanced alternative plan that provides coverage in the coverage gap."

CMS also requires all Part D plans that intend to drop out of the market in 2007 to notify their enrollees, the general public and CMS of that fact by Oct. 1, 2006. That notification "must include a written description of the alternatives available for obtaining qualified prescription drug coverage" within the enrollees' region, the CMS call letter says.

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