CMS Resources Describe Drug Coverage Determinations Under Medicare

By News Staff
2/23/2006

The Jan. 1 launch of Medicare Part D focused many patients' attention on outpatient prescriptions, and many may think Part D, whether submitted to a retail pharmacy or administered by a physician during an office visit, covers all their medications.

Not true. CMS has published an online description (PDF file: 42 pages / 817 KB. More about PDFs.) of Medicare drug coverage determinations under Part A, Part B and Part D. In addition, CMS has asked medical specialty societies, insurance associations, consumer groups, long-term care associations and pharmacy organizations to distribute two charts -- "Medicare Drug Coverage Under Part A, Part B, and Part D" (PDF file: 5 pages / 54 KB. More about PDFs.) and "Part D Drugs/Part D Excluded Drugs" (PDF file: 3 pages / 62 KB. More about PDFs.) -- to their members for them to use in explaining to patients which plans cover which drugs.

According to the documents, Part D covers drugs that are available only by prescription and that are used for medically accepted indications. It also covers insulin, vaccines and other biological products. The definition covers medical supplies associated with injection of insulin but not glucose test strips or lancets. Medications that are excluded by law from Part D coverage include benzodiazepines, prescription vitamins and minerals, heparin or saline flushes, and barbiturates.

The coverage determination documents supplement other Medicare Part D tools published by CMS on the Part D Formulary Information for Physicians page. Among them are

"Exceptions and Appeals Contact Information," (MS Excel file: 154 pages / 465 KB. More about downloading files.) -- a guide for physicians that provides names, telephone and fax numbers, and some e-mail addresses for appealing insurance companies' Part D coverage determinations;
"Pharmacy Technical Support Contact Information," (MS Excel file: 134 pages / 735 KB. More about downloading files.) -- a guide for pharmacists that provides names of Part D insurance companies and the companies' telephone numbers or e-mail addresses for appealing Part D coverage decisions;
"Medicare Prescription Drug Coverage Provider Communication Form" (PDF file: 1 page / 23 KB. More about PDFs.) -- a form allowing pharmacists to communicate with physicians regarding prescription information or change requests;
a letter to physicians, (PDF file: 3 pages / 249 KB. More about PDFs.) that describes the 90-day grace period during which plans must cover all medications and that guides them to the CMS formulary finder and other information provided by CMS to physicians and pharmacists;
"Model Coverage Determination Request Form" (PDF file: 2 pages / 23 KB. More about PDFs.) -- a model form that physicians can use to request coverage determinations from insurance plans; and
"Instructions for the Model Coverage Determination Request Form" (PDF file: 1 page / 15 KB. More about PDFs.) that directs physicians on how to use the model coverage determination request form.