The Medicare Modernization Act gave Medicare Part D plan sponsors flexibility to
create their own formularies. So, in January 2006, should pharmacists expect a
deluge of “NDC Not Covered” or “Prior Authorization Required”
rejects?
Not according to the Centers for Medicare & Medicaid
Services (CMS). Last week, potential prescription drug plan sponsors (PDPs)
were required to submit their proposed formularies to CMS for review to “ensure
that plans offer a comprehensive array of drugs that reflect best practices in
the pharmacy industry as well as current treatment standards.”
However,
it is likely that many plans will include tight formularies with extensive
tiering structures that will employ step therapy, prior authorization, and other
methods to control drug spending. Many beneficiaries, especially those
transitioning from the open formulary of the Medicare drug discount cards and
Medicaid, will need to change their existing therapy to covered Part D
drugs.
Pharmacists can tell patients that they will have a 30-day grace
period to continue taking a non-formulary medication next year. In a guidance
released last month, PDPs will be required to have a transition plan to maintain
beneficiaries on current treatment until the plan or beneficiary can contact the
provider for any necessary therapy changes. In most cases, the Part D plan
will cover existing medications for 30 days. But in the long term care setting,
the plan may need to cover existing medications for 90 to 180 days.