Now that the initial transition phase has ended for Medicare Part D
beneficiaries, most patients will be presented with formulary management
requirements by their Part D plan. That includes prior authorization and step
therapy requirements. While these requirements are in place to keep medication
costs for the Part D plans down, there are safeguards in place to ensure that
patients receive needed therapy outside normal formulary management techniques.
In the event that a patient does not have access to their needed medications
due to restrictive formulary management requirements, patients can file formal
formulary exceptions and appeals to petition their plan. This is a new
process rarely seen in the private marketplace. Many pharmacists and Medicare
patients may be unaware that such safeguards exist
Under the Medicare Modernization Act (MMA), Part D plans are required to post
or distribute notices instructing enrollees on how to send a formal appeal in
network pharmacies. The Centers for Medicare and Medicaid Services (CMS) has
requested that all pharmacies post a model pharmacy notice. Click here to download it.
More information is provided here.