Continuity of Care and Transition Policies

We have been receiving many reports that prescription drug plans (PDPs) are not following CMS policies on the continuity of care for beneficiaries who were stabilized on antidepressants, antipsychotics, and anticonvulsants when their Part D coverage began.  We have been receiving a similar volume of reports that the one-time transition prescription coverage required under CMS guidances for enrollees requiring nonformulary drugs is not being provided.  Because of this, we feel it’s important to supply this reiteration of CMS’s continuity of care and transition policies.

Continuity of Care
CMS has stated that patients who enter Part D coverage stabilized on drugs in any of the six protected categories (antidepressant, antipsychotic, anticonvulsant, anticancer, immunosuppressant, and HIV/AIDS) are to be permitted to continue to receive refills of the specific drugs they are already taking, regardless of the formulary of the prescription drug plan (PDP) in which they are enrolled.  (It is not required that the medications be available in the same form or dosage that the patient has been taking.) Even though the PDP may apply utilization management (UM) techniques such as prior authorization or step edits to these drugs for new prescriptions, CMS has stated that no UM is to be applied to refills for patients stabilized on drugs when they enter Part D coverage.

The only prior authorization for these drugs that is permitted is for what CMS refers to as safety edits.  These are edits that are put in place to ensure the prescription is correct as written.  They should only occur when the dosage prescribed is outside the norm or when a drug is being used off label, for a diagnosis outside those listed in the FDA approval.  Once the prescriber assures the PDP that the prescription is correct and meant to be filled as written, the patient should receive the medication, and the patient should continue to receive the drug as long as it is medically necessary (not just on a 30-, or 60-, or 90-day basis).  

There is one problem with this policy that has been occurring, because, even though every PDP is expected to have every drug in the protected classes in its formulary, the PDPs are not required to have every dosage and form of the drugs.  If a patient is taking a very high dosage of an antipsychotic, for example, but the PDP only has low doses on its formulary, the PDP’s quantity limits for that drug, 30 or 60 pills a month, may make it impossible for the patient’s continuity of care to be maintained.  (Since this would seem to subvert CMS’s continuity of care guidance, we are making inquiries to CMS in the hope of having this loophole eliminated.)  Currently, in cases like this, Part D’s transition policy (see below) should ensure that the patient receives the necessary drugs for at least 90 days until an accommodation can be worked out, either through appeals or a change in regimen.

Part D Transition Policy
CMS created a transition policy to cover situations where an enrollee goes to a participating pharmacy with a prescription for a drug that is not on her PDP’s formulary “unaware of what is covered by the plan or what is included in the plan’s exception process to provide access to Part D drugs that are not covered.” To allow the patient time to employ the PDP’s exceptions process, CMS has said that the enrollee should be granted a one-time transition supply of the prescription drug, even though it is not on the formulary.  (Because all drugs in the six protected classes are expected to be on every formulary, the transition policy should only have to apply to drugs in other categories, except for the current situation described above.) Originally the one-time transition supply was expected to be available for 30 days, but because of problems in the implementation of Part D, CMS extended the transition supply period to 90 days. 

As stated above, patients who need refills of their drugs in the protected categories (which are supposed to be on every formulary), but who cannot get access to their required drugs because of quantity limits, should be able to get at least a 90-day supply until an appeal can be processed or a change in regimen can be made without compromising the patient’s health.

We Need Your Help

From the reports we’ve received thus far, we have reason to believe that some PDPs may be exhibiting a pattern of noncompliant conduct rather than just making an occasional simple error.  It is only through an accumulation of data from the field that we will be able to petition CMS to exercise its enforcement authority and make the offending PDPs comply with the stated Part D continuity of care and transition policies.  If you have run into any problems with PDPs failing to follow the continuity of care and transition policies or have any questions, please contact us at PartD@psych.org or 866-882-6227.