American College of Physicians: Internal Medicine — Doctors for Adults ®


Will the new drug benefit affect physician workflow?

From the December ACP Observer, copyright 2005 by the American College of Physicians.

By Neil Kirschner, PhD

Q: How will the new Medicare Part D prescription drug benefit, which takes effect next month, affect my practice?

A: The new drug benefit could affect your workflow in several ways. For one, more than 6 million "dual eligibles"—Medicare beneficiaries who also qualify for full Medicaid benefits—will now be enrolled in a Medicare drug plan. Some of these patients may find themselves in a drug plan that doesn't include their medications.

Q: Can't dual-eligible patients choose plans that cover their drugs?

A: Yes, they can. But dual eligibles who do not themselves enroll in a prescription drug plan by Dec. 31, 2005, will be automatically and randomly enrolled in one by the Centers for Medicare and Medicaid Services (CMS), with coverage beginning Jan. 1, 2006. Those enrollments will be made without consideration for how a plan's formulary matches specific medication needs.

As a result, many patients will be taking medications not included in the formulary of their new drug plan. Also, many of these patients may not understand the changes taking place in their medication coverage—or may not make the best choice among different plan options.

Q: What can I do to help dual eligible patients?

A: For one, be aware that all Medicare drug plans must have transition procedures, such as allowing patients to have a one-time, 30-day supply of a non-formulary drug. Those procedures are designed to give prescribing physicians time to switch patients to another medication or complete an exceptions request.

You also need to let dual eligible patients know that they can change their drug plans at any time without penalty. Patients can call 800-MEDICARE or visit the Medicare Web site to get help in finding a plan that better meets their needs.

Q: Will I have to spend more time using the exceptions and appeals process?

A: Probably. All Part D drug plans are required to have a process allowing enrollees to challenge the exclusion of a particular drug from the formulary or the placement of a drug in a higher cost-sharing tier. Although you may have experienced these procedures before, you'll find an increasing number of situations in which a plan must grant an exception or approve an appeal.

Q: How can I stay on top of that process?

A: Start by becoming familiar with the formularies and exception/appeal procedures of your local area plans. Medicare will be making a special effort to make this information available to physicians through plan literature, Web sites and PDA-downloadable sources.

Q: How do the exceptions and appeals procedures work?

A: Here is a basic outline:

  • First step: Request an exception. The enrollee, the prescribing physician or the enrollee's legal representative can request an exception, called a determination. Generally, plans must grant exceptions that are determined to be medically appropriate, based on information provided by the prescribing physician. Plans must make determinations as quickly as an enrollee's health condition requires—but no later than 24 hours for decisions involving enrollees who suffer from serious health conditions and 72 hours for standard decisions.

  • Second step: first-level appeal. In the event of an unfavorable determination, an appeal request can be made to the Part D plan. The plan must respond to this first level of appeal, called a redetermination, within 72 hours for expedited decisions and seven days for standard decisions.

  • Third step: second-level appeal. If the Part D's plan redetermination is denied, a second-level appeal, called a reconsideration, can be requested. This is conducted by an independent review entity (IRE), which is independent of the Part D plans. The timeline for an IRE reconsideration is the same as a first-level appeal redetermination. Enrollees can pursue higher levels of appeal if the IRE's decision is unfavorable.

Q: How might utilization management tools affect my practice?

A: Medicare drug plans will likely employ utilization management tools to control their costs, so more of your patients will belong to drug plans that use these tools and require physician documentation to receive medication. Again, you should get to know the tools used and procedures required by the drug plans in your area.

Utilization tools include:

  • Tiered formularies. These require enrollees to have different copays for drugs that cost more within the plan.

  • Prior authorization. The prescribing physician must request coverage for a medication and provide necessary documentation.

  • Step therapy. The physician must use a preferred drug for a condition before being allowed to prescribe a different drug.

  • Quantity limits. These put a limit on the number of tablets or doses permitted each month or on the duration of the therapy before new approval is required.

To help physicians with these and all other concerns related to the new Medicare Part D benefit, ACP has established a new Web site. The site provides helpful materials about the new benefit for you, your staff and your patients.

Neil Kirschner, PhD, is Senior Associate for Regulatory and Insurer Affairs in ACP's Washington office.


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