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Transition & Continuity of Care
The transition of many Medicare patients from their current drug coverage to coverage under Part D creates a number of concerns about how patients will be able to continue to receive the medications on which they are currently stabilized. This transition applies in three different situations: the initial transition of beneficiaries to Part D on January 1, 2006; the transition of new enrollees after that date; and the transition of individuals who switch from one plan to another after the implementation of the benefit.
CMS has acknowledged the specific needs of patients with mental illness to be able to continue on their same drug regimens. In their online FAQs (http://questions.cms.hhs.gov ) states “beneficiaries should be permitted to continue utilizing a drug in these categories that is providing clinically beneficial outcomes.” It is important to understand that CMS’s transition policy is suggestive rather than mandatory and is being revised regularly as more issues come into question. We will provide updates as new information becomes available.
Of special concern are the difficulties that may arise for dual eligible patients, patients with both Medicaid and Medicare, who have been receiving drugs through their state Medicaid programs. Although these patients will be automatically enrolled in a low-premium prescription drug plan (PDP) by CMS to ensure that they will not have a gap in coverage, there are questions about whether the new plans will provide them with the exact same medications they are currently receiving and about the co-pays they will now be responsible for under Part D. Because these patients will be permitted to switch to more appropriate plans as needed, they and their caregivers will likely turn to their psychiatrists to help them make informed decisions.
Questions Answered
The Centers for Medicare and Medicaid Services (CMS) recently announced a new point of sale (POS) fallback plan for dual eligible patients (individuals eligible for both Medicaid and Medicaid) who, for whatever reason, failed to be enrolled in a pharmacy benefit plan, as part of the autoenrollment process for duals. When dual eligible patients appear at the pharmacy because they need a refill of their medication, if the pharmacist is unable to verify that the customer has been enrolled in a drug plan using the new centralized query system established by CMS, the point of sale (POS) protection plan will go into effect. » Click here to read the full answer.
Medicaid coverage ceases on December 31, 2005, and Medicare Drug coverage begins January 1, 2006.
As stated above, CMS has acknowledged the specific needs of patients with mental illness to be able to continue on their same drug regimens. In August 2005, the APA requested clarification in writing as to how this would work. Although no written response has yet been provided, at a September meeting with the APA, CMS staff stated that patients who present at a pharmacy after January 1, 2006, with refills will be presumed to require those drugs to maintain their stability and are to be provided with them as long as the drugs are on the plan formulary. If the required drugs are not on the formulary at all, or not on the formulary in the form or dosage requested, PDPs may require that a request for an exception be filed to adjudicate access to the needed drugs.
What is CMS’s guidance concerning temporary/emergency one-time-supply refills?
CMS requires that a PDP’s transition process “address situations where an individual first presents at a participating pharmacy with a prescription for a drug that is not on the 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.” PDPs are to consider “processes such as the filling of a temporary one-time transition supply in order to accommodate the immediate need of the beneficiary and to allow the plan and/or the enrollee time to work out with the prescriber an appropriate switch to another medication or the completion of an exception request to maintain coverage of an existing drug based on reasons of medical necessity.” CMS has suggested that a first-fill supply of 30 days would be a reasonable standard.
CMS’s guidance on unplanned transitions stipulates that beneficiaries and providers “need to utilize the PDP’s exceptions and appeals process.” CMS acknowledges that “there may exist some period of time in which beneficiaries have a temporary gap in coverage while an exception or appeal is undertaken,” and suggests but does not require that plans utilize a one-time supply fill to cover this gap as the enrollee goes through the plan’s exception process.
What is CMS’s current transition policy for patients in long-term care facilities?
CMS’s guidance states, “the transition process take into account the unique needs of residents of long term care (LTC) facilities who enroll in a Part D plan.” Where there are gaps between an LTC resident’s current regimen and a PDP’s formulary, CMS notes that PDPs “may need to provide a temporary first-fill supply order for a limited quantity of medication prescribed by a physician.” The suggested transition period for a first-fill supply order is 90 to 100 days rather than the 30 days suggested for all other situations.
How can I find out about the transition policy of a specific PDP?
CMS has stated that PDPs “must make transition processes available to beneficiaries available in a manner similar to information provided on formularies and benefit design.” This means this information should be available from the plan directly upon request or online at www.medicare.gov.
It is essential to be able to determine if a plan’s formulary, utilization management requirements, and transition policies will permit the continuation of a proper course of care for your patient
In October 2005, the CMS website, www.cms.gov (for providers) and www.medicare.gov (for consumers), is expected to post the list of participating drug plans in each region along with each plan's formulary, including the utilization management techniques that will be employed. This information will also be available by phone at 1-800-MEDICARE (1-800-633-4227).
Enrollees will be able to review plan formularies and utilization management techniques starting in mid-October, and this will hopefully allow them to choose a plan that better fits their medication needs (see above). CMS has stated that if a patient is stabilized on certain drugs, the new plan must continue to provide these same drugs when the patient requires a refill, so this may help solve the problem of plan selection for them. The plan is not, however, obligated to provide the drug in the same form or dosage the patient has been getting. Therefore, if the patient’s medication is not available as needed, an exception will have to be filed with the PDP or the patient will have to look for a PDP that can supply the necessary drugs.
Should I refill my dual eligible patients’ current prescriptions by December 31, 2005?
As a general rule, you should refill your patients’ current prescriptions prior to January 1, 2006, if this is permitted by the state Medicaid program.
Will my patient be able to fill prescriptions in the way they always have?
Enrollees will need to have their prescriptions filled at a pharmacy that participates with their plan. This means that patients should also look at participating pharmacies choices when choosing a plan that’s best for them.
It is important to note that there are still many uncertainties about the specifics of how PDPs will operate. Therefore, it is not possible to make predictions at this point about what patients will encounter at the pharmacy. The APA has developed a flowchart for possible scenarios when a dual eligible patient visits the pharmacy after January 1, 2006. [link to At the Pharmacy flow chart
Current as of 12-19-2005
