When Writing Prescriptions, Specify 'For Part D'

Simply using the phrase, "for Part D," could save physicians a lot of trouble when prescribing medications covered by Medicare's prescription drug benefit that also are covered under Medicare Part B for other indications.

When a Medicare Part D plan receives a prescription for a drug that also can be prescribed under Part B, Medicare rules require plan managers to verify that the drug is being used for a disease that would not trigger Part B coverage.

"Initially the plans instituted cumbersome prior authorizations procedures which required that the prescribing physician fill out a prior authorization form and send the form to the plan. In order to simplify the process, CMS has instructed the plans that if a prescription is written for a B/D drug and the prescription has written on it the words 'Part D' and a part D diagnosis, such as 'contact dermatitis,' the prescription should be filled," advises CMS in a new MLN Matters article (PDF file: 5 pages / 156 KB. More about PDFs.).

This clarification should streamline the process for physicians who want to prescribe prednisone for rheumatoid arthritis, which would fall under Part D coverage, rather than for preventing rejection of an organ transplant, which comes under Part B. That same rationale would hold true for methotrexate, which is used as a chemotherapy agent, or any other drugs that are prescribed in some cases under Part B and in others under Part D, according to CMS officials.

"Plans may rely on physician information included with the prescription, such as diagnosis information (e.g., to determine if the prescription is related to a Medicare covered transplant) or location of administration (e.g., to determine if the prescription is being dispensed for a beneficiary in a nursing home) to the same extent they rely on similar information acquired through documentation from physicians on prior authorization forms," the article recommends.

Although the article also states that Part D plan managers ultimately are responsible for making coverage determinations, they will be judged to have met "appropriate due diligence standards" without further documentation from a physician if enough information is provided on the prescription and the pharmacy is able to communicate that information to the plan managers.