Medicare Part D Barriers Expected to Come Down Over Time

Physicians can expect fewer administrative complications but ongoing formulary issues -- particularly for disabled and chronically ill patients -- in upcoming weeks as they write prescriptions for their Medicare patients.

Medicare Part D plans will continue to deny payment for all medications that fall within nine drug categories that are specifically prohibited under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, according to Barbara Cebuhar, a spokeswoman for CMS. Those classes include benzodiazepines; barbiturates; agents used for anorexia, weight loss or weight gain; and agents used for symptomatic relief of cough and colds.

However, Medicare patients who also qualify for Medicaid can continue getting prescriptions for these medications under 49 state Medicaid programs. Only Tennessee Medicaid denies coverage for these medications, according to a CMS Web site that links to information on state Medicaid drug coverage.

The states' interventions have helped physicians navigate formulary limitations for Medicare patients with conditions such as epilepsy, cerebral palsy, anxiety disorders, insomnia or failure to thrive due to other medications or conditions, as well as those with pain due to life-limiting illnesses, such as cancer.

Resolving Glitches
The administrative problems that dogged the launch of Medicare Part D likely will resolve over time. However, confusion may persist through February, warned a spokesman for America's Health Insurance Plans, which represents health insurance companies, including those that provide Part D prescription plans.

"Over January, we have done a lot of work on systems issues," said Mohit Ghose, AHIP spokesman. "At the same time that our members have been waiting for information from CMS, we've been working with pharmacists and physicians to provide (temporary) work-around policies that should let patients get their medications in the interim."

For patients who are told at the pharmacy counter that they don't have coverage because their insurance plan hasn't had time to process paperwork, this stop-gap coverage will allow them to get 14 days of medications while any permanent plan in which they've enrolled resolves administrative and formulary issues.

All Part D plans must cover a patient's current drugs at current dosages during a 90-day grace period, but coverage begins on the first day of the month after a patient enrolls, said Ghose. A patient who enrolls in February will have coverage March 1, but if that patient enrolled in late February, the insurance company may not have had time to process the enrollment before the patient uses the coverage.

"Physicians can encourage their patients to sign up for a plan before the middle of the month," said Ghose. That will allow insurance companies to complete necessary paperwork, send the patient a prescription card and enter the patient's information in the pharmacy database. It also will enable the physician to identify any prescriptions excluded from the plan's formulary, help the patient adjust to a covered substitute drug or complete preauthorization or appeals paperwork, he said.

Academy Interventions
Throughout the launch of Medicare Part D, the Academy has worked with CMS, the MedicareRx Education Network and AMA to address issues raised by physicians, according to Susan Hildebrandt, assistant director of the AAFP Division of Government Relations. The Academy's online Medicare Part D resource page provides links to numerous tools to ease the transition to Medicare Part D. Among them are

In addition, AAFP and the AMA are collaborating on a single form that physicians can use for preauthorization or appeals correspondence with all Part D insurance plans when prescriptions are denied, said Hildebrandt.

"CMS asked us to do this and we're meeting with AHIP officials to work on this together," said Hildebrandt. "The goal is to streamline this process for physicians."