Letter From CMS to Providers

Dear Health Care Professional:The new Medicare Part D prescription drug program is the single biggest change to Medicare since the program began 40 years ago and one which has been long overdue. But adding a benefit as significant as the new Medicare prescription drug program, which affects millions of individuals, involves some start-up challenges.

We’re writing today with the objective that, during this initial period, CMS and providers keep lines of communication open. Physicians may occasionally need to help a patient by filing a prior authorization for a medication or appeal a medication’s tier. We want to make it as easy as possible for you to help your Medicare patients, as well as to ensure that you get the support you need if questions arise. Here’s a brief glossary of terms that may assist you in working with your patient’s prescription drug plan:

• Coverage determinations: The first decision made by a plan regarding the prescription drug benefits an enrollee is entitled to receive under the plan, including a decision not to provide or pay for a Part D drug, a decision concerning an exception request, and a decision on the amount of cost sharing for a drug.

• Exceptions: An exception request is a type of coverage determination request. Through the exceptions process an enrollee can request an off-formulary drug, an exception to the plan’s tiered cost sharing structure, and an exception to the application of a cost utilization management tool (e.g., step therapy requirement, dose restriction, or prior authorization requirement).

• Appeals: The process by which an enrollee may challenge a plan’s coverage determination. There are five levels in the appeals process: redetermination by the plan, reconsideration by the Part D QIC, an ALJ hearing, review by the Medicare Appeals Council, and review by a federal district court.

CMS has directed every prescription drug plan to have an expedited request process to communicate coverage decisions no less than 24 hours after receiving an expedited request, or 72 hours after receiving a standard request. We’ve provided an exceptions and appeals contact list for each prescription drug plan on the CMS website. To see this, click on:

http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/04_Formulary.asp.

For more about the exceptions and appeals process, please go to

http://www.medicare.gov/Publications/Pubs/pdf/11112.pdf.

You will find a CMS publication that explains how to file a complaint, coverage determination, or appeal.

CMS is committed to making sure that beneficiaries covered under Part D get the drugs they need. However, in the event that backup systems fail, we are urging people with Medicare—and we hope you will do the same—to call 1-800-MEDICARE immediately so we can resolve the issue and get them their medication. But we want to let you know about the following additional resources that you can call on for support:

1. For your patients, CMS caseworkers can provide one-on-one help. We have hundreds of trained caseworkers working with Medicare beneficiaries to resolve any issues that may arise with this transition. If you have a patient who needs casework assistance, please call 1800-MEDICARE. Phone lines are open 24 hours a day, seven days a week.

2. CMS offers a formulary finder to enable you to find plans in your state that match the patient’s required drug list. It is linked to all plan formularies at: http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp. If you are not sure whether the drug you prescribed is a Part B drug or a Part D drug, you can consult our Part B versus Part D coverage chart found at: www.cms.hhs.gov/pharmacy/downloads/partsbdcoverageissues.pdf.

3. Epocrates, the medical software company, offers PDP formulary information on its website. It provides both tier and step therapy information, is updated constantly, and can be easily accessed by computer or downloaded to a PDA at: http://www.epocrates.com.

We also want to bring your attention to the Request for Prescription Information or Change form. This is a general fax form to expedite communications between pharmacists and physicians. It was created by a coalition of medical societies and advocacy groups and can be found at: http://www.cms.hhs.gov/prescriptiondrugcovgenin/04_formulary.asp.

Finally, we’d like to let you know about some steps we’ve taken to support pharmacists who work with Medicare Part D. These include:

• Setting up a dedicated phone line for pharmacists to help answer questions regarding billing and beneficiary enrollment information;

• Distributing a new pharmacy computer tool, “E-1,” that provides pharmacists with real-time enrollment and eligibility-search information;

• Requiring plans to cover a standard 30-day supply of transitional prescription medication. CMS has approved transition procedures for all Medicare prescription drug plans to provide patients who are on stabilized drug regimens with at least a 30-day supply of their current medication, even if their particular drug is not on their plan’s formulary. Plans have also been asked to extend this temporary coverage on a case-by-case basis; and,

• A point of sale option that allows a beneficiary who is eligible for Medicare and Medicaid to join a plan at the counter to get the drugs they need. For examples of common situations, click on: http://www.cms.hhs.gov/Pharmacy/Downloads/whatif.pdf.

If you wish to communicate with CMS directly, please contact the Physicians’ Regulatory Issues Team (PRIT). You can e-mail PRIT@cms.hhs.gov and let us know what problems you might be encountering—we’ll do everything we can to help address those issues. If you would like to speak to us in person, please take advantage of our regular conference call at 2pm EST every Tuesday. This gives you an opportunity to ask questions directly of CMS staff. Call 1-800-619-2457. Pass code: RBDML. More information about PRIT is available on cms.hhs.gov.

We look forward to continuing to work with you to implement the new Medicare prescription drug coverage. Your help is invaluable in making sure that every Medicare beneficiary is able to get the medication they need.

Sincerely,

Jeffery Kelman, MD

William D. Rogers, MD Chief Medical Officer Director,
Physicians Regulatory Issues Team Center for Beneficiary Choices Office of External Affairs