Questions Answered NEW What happens if an individual needs to access medications when they are out of their region? CMS is aware that there are instances in which a beneficiary may need to access drugs at an out-of-network pharmacy. Plans are required to assure that their enrollees have adequate access to drugs dispensed at out-of-network pharmacies when they cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy. Provided that such access to out-of-network pharmacies is not routine, we expect that plans would guarantee out-of-network access to beneficiaries when, for example they are: (1) traveling outside their plan’s service area and run out of or lose their covered Part D drugs or become ill and need a covered Part D drug, and cannot access a network pharmacy; (2) not able to obtain a covered Part D drug in a timely manner within their service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24/7 service; (3) filling a prescription for a covered Part D drug and that particular drug (for example, an orphan drug or other specialty pharmaceutical) is not regularly stocked at accessible network retail or mail-order pharmacies); (4) administered a vaccine covered by Part D in a physician’s office; and (5) provided covered Part D drugs dispensed by an out-of-network institution-based pharmacy while in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting. We will closely monitor out-of-network access to ensure that plans are adequately meeting enrollees’ out-of-network access needs. Plans will have some flexibility to establish reasonable rules to assure that enrollees use out-of-network pharmacies appropriately. When an enrollee purchases a drug at an out-of-network pharmacy under these circumstances, he or she will pay the same cost-sharing as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy’s price and the network pharmacy price for that drug. NEW Are the Plan Finder and Formulary Finder fully functional? According to CMS, yes, and all information is accurate to what was provided to them by the plans. On November 7, detailed pricing data was added to the site, allowing users to compare drug costs and calculate total costs for the individual based on their medications. On November 14, the online enrollment center and a Spanish-language version of the Plan Finder tool were added to the site. There are still some issues: slow site, links not functioning, but generally it’s working. Some tips/new features: The online enrollment tool can assist in enrolling individuals in all plans except the 54 that chose not to participate in that option (waiting for clarification from CMS). Users can access the online enrollment form by clicking on an Enroll in a Plan button in five locations: On the Plan Finder homepage After searching the Plan Finder, each Plan detail page has a link to enroll On the Personalized search page On the detailed cost comparison page On the Medicare.gov personal plan finder page (for general Medicare plans) When doing a search based on medications, the tool will identify plans which cover the search medications and the user can click on the medication to get further detail about whether prior authorization, step therapy or quantity limits apply, and what copayment tier the medication is in. An ** in that box indicates a non-formulary medication. In late November, duals will be able to enter their personal information and automatically be able to compare the plan to which they’ve been autoenrolled to other plan options in their region. When conducting a personalized search for an individual, CMS admitted that dual eligibles are not differentiated from individuals eligible for the Extra Help, so the default information on copayments will show $2-5, rather than the $1-3 that will be applicable to most full benefit duals. The Plan Finder/Formulary Finder tool will only identify network pharmacies within a 50 mile radius of the individual. In rural states, this may (and is) limiting the choice of plans in some cases. When entering medications to conduct a personalized search, users are not able to enter the same medication in two different dosages (e.g., if an individual is on the same medication but different dosages in the morning and evening – and thus two separate prescriptions). CMS is aware and I await a response on how to get around that… Some plans are offering no copays – principally for generic medications only. Which medications used to treat mental illness won’t be included on the formularies? Several medications used in psychiatric care will not be included in the PDP formularies: Barbiturates and benzodiazepines are legally excluded from coverage by the Modernization Act (MMA), which created the prescription drug benefit. Other drugs used in psychiatric care that may be excluded per formulary guidance include: Escitalopram or citalopram (antidepressants) – only one must be included Fosphenytoin (anticonvulsant) may be excluded It is expected that most states will continue to provide the drugs that are legally excluded from coverage by Medicare for patients with both Medicare and (). The APA is currently conducting a survey of how state Medicaid programs will respond to the needs of dual eligibles. Will the formularies cover other medications used to treat mental illnes? CMS has recommended that “all or substantially all” of the drugs in the antidepressant, antipsychotic, and anticonvulsant therapeutic categories be included in plan formularies. This does not mean, however, that all forms and dosages of these drugs must be included, only that some version of the medication must be on the formulary. It should be noted that drugs used for the treatment of substance use disorders do not fall within the “all or substantially all” categories. The "all or substantially all" policy will be in place for 2006, and will be reviewed for 2007. How can my patients find out which plans include their current medications? CMS has indicated that starting in October 2005, information comparing different plans, including the medications on their formularies and the utilization management techniques they’ll employ, will be available through www.medicare.gov, 1-800-MEDICARE, and through . may also be able to provide assistance. (This will be updated as soon as plan information is released by CMS.) Will my patients have to switch medications if their current drugs aren’t on the plan’s formulary? CMS has said that it will assume patients already in treatment are stabilized on current medications and will expect PDPs to make those same medications available without restrictions. Therefore, a patient presenting for a refill on or after January 1, 2006, will be presumed to be clinically stabile and entitled to the refill medication on demand. It is unclear, however, whether the PDPs will have to provide the drugs in the same dosage and/or form the patient is currently taking. There is also some concern that if the drug is not available as prescribed, an request may be necessary to bypass utilization management protocols (See Utilization Management). These issues are currently being discussed with CMS, and it is hoped that these discussions will clarify what constitutes a valid refill request. What if I wish to prescribe a medication not on my patient’s PDP formulary? Physicians who wish to prescribe a medication that is not on the patient’s plan formulary, or which is restricted by utilization management techniques, can request an exception from the plan. Each plan is required to have a process in place for considering these exceptions. For more information, see section on Coverage Determinations, Exceptions, and Appeals Can the plans change formularies after enrollment? Yes, plans can change the medications on their formularies. For example, plans can discontinue coverage of a drug, or change their management techniques. However, they must provide at least 60 days notice to affected enrollees, physicians, and pharmacists, among others, before the changes take effect. During this time, plan enrollees should be able to seek an exception to the new formulary (see section on Coverage Determinations, Exceptions, and Appeals). How can my dual eligible patients, who currently receive drugs under Medicaid, get an emergency supply of medications after January 1, 2006?? In some states, physicians may be able to help ease their patients’ transition to the new plans by providing a prescription for a 30- to 90-day extended supply of needed drugs to be filled in December 2005. Each state will have its own policy on this. (The APA has undertaken a state-by-state analysis on this issue which will be available soon.) Should my patients refill their prescriptions by December 31, 2005? Yes. It is advisable for patients to play it safe and get a supply while it is certain the needed drug is available. Also, this gives time to start the exceptions process in January without potentially having the patient go without needed medications while the process takes its course. CMS recommends that Medicaid plans provide a refill supply of medication to see patients through the transition period, but this is likely to vary from state to state. While CMS doesn’t specify the time period the refill should cover, they say that at least 30 days is reasonable for patients who first visit a pharmacy with a prescription for a drug not on the formulary (a longer supply of 90-180 days is suggested for patients in long-term care facilities). The goal is to give the PDP and/or enrollee enough time to contact the physician about substituting another medication or requesting an exception to the new formulary if there is no acceptable substitution.