Mental Health Part D News Alert

January 11, 2006

Important Updates on Part D Implementation

As we begin implementation for Part D, there are several challenges emerging across the country.  The problems are system-wide, affecting all or most prescription drug plans (PDPs).  The mental health advocacy groups are working with CMS to report problems and provide the latest updates as the situation develops.  If you have information, please contact us at PartD@psych.org or call 866-882-6227 with feedback on specific situations.

Large volumes of reports have highlighted four main issues of concern:

• Enrollment.  The Point of Sale protection plan initiated by CMS (see detailed information on the POS plan) is experiencing several difficulties.  In some cases, the system is not being used within pharmacies to provide a fallback mechanism for dual eligibles to obtain medications, and other reports indicate that the POS system is not functioning properly when accessed.
• Transition policies.   Although CMS has stated that all PDPs must have policies in place for providing transition or one-time refills of medications to individuals already stabilized on a medications (see detailed information on Transition), PDPs are not always honoring this policy and patients have been denied access to medications. 
• Co-payments and deductibles.  Although dual eligibles are not subject to deductibles under Part D, some pharmacies have been insisting they pay the standard $250 deductible before receiving their medication.  In other cases, dual eligibles are being charged copays higher than the $1-$3 copays mandated by the Part D regulations.  One reason for this problem is that when duals were auto-enrolled into a Medicare PDP, the new plans did not receive the information that the new enrollee was a dual eligible.  CMS says it is working to resolve this issue.
• Prior authorization and step therapy.  PDPs are frequently requiring patients to seek prior authorization or step therapy before obtaining medications, and patients cannot obtain their medications immediately.  For more information, please see Transition & Continuity of Care and Utilization Management.

Mental health advocates have provided considerable input to CMS about these issues.  In response, CMS has distributed a letter to all PDPs to remind them of transition policy requirements.  CMS has asked advocates to distribute the letter to patients so that they can present this document at the pharmacy as a means to reinforce CMS’ transition policy and obtain their medications.

Click here to download the letter from CMS outlining required PDP transition policy.

We do not believe that this letter will be a full or quick remedy for the current situation, and we continue to ask for your assistance in reporting questions or problems.  Please contact us at PartD@psych.org or call 866-882-6227 with feedback on specific situations.