Medicare drug not covered? You can help patient appeal

Washington -- A Medicare patient shows up at his primary care physician's office distraught because his Part D plan doesn't cover the drug he's been taking for years. Suddenly he's faced with out-of-pocket charges he can't afford and a prescription that he can't get filled.

This scenario might become more common at the end of this month.

After March 31, Medicare drug plans can stop paying for federally mandated transitional supplies of noncovered medications that are prescribed to beneficiaries who enrolled in the drug program in its first few months. Patients then will need to start paying on their own for the medications or consult their physicians about switching to similar drugs that will be covered.

But many beneficiaries will be unable to afford the drugs that they previously had been receiving through Medicaid or another program, and some of them won't be able to switch to another medication for medical reasons. That's where the Medicare appeals process comes in.

If a drug plan denies a patient's request for coverage of a certain drug, the beneficiary or physician can take the request through as many as five levels of appeal. The process starts with the insurer, moves onto adjudicators hired by the government and, in cases where the dollar value of the drugs in question is high enough, can end up in the federal court system if all of the other appeals levels are exhausted.

While beneficiaries can initiate and renew appeals, in many cases physicians will need to become involved if they want to see their patients receive drugs that are not on plans' approved lists.

Any time a patient needs a drug that is not on his or her plan formulary -- or if the patient wants to have a nonpreferred drug considered the same way as a preferred medication -- the patient's doctor must provide the plan with a statement supporting this request.

A physician statement also is required to expedite an appeals process for cases in which waiting the standard length of time before receiving a decision could jeopardize a patient's life, health or recovery time.

The supporting statement requirements mean that physicians must realize that they are an integral part of the appeals process, said Vicki Gottlich, a senior policy attorney at the nonpartisan Center for Medicare Advocacy in Willimantic, Conn. The center works to increase access for seniors and disabled people to comprehensive Medicare coverage.

"Physicians are the major player in this process," she said. "You can't get the formulary exception, you can't get the variation from the prior authorization or step therapy requirements without the doctor's participation."

At a minimum, oral or written supporting statements must demonstrate that a beneficiary needs a nonpreferred or noncovered drug because medication alternatives would cause harm to the patient, would not be as effective or both.

Some physicians who have been through the process have complained about the need to follow different requirements for different drug plans, Gottlich said. Each insurer typically has its own coverage request form and set of instructions for physicians' supporting statements.

The result can be a headache that some doctors might not want to experience, especially if a request requires too much supporting data or goes through more than one level of appeal, said Joel Brill, MD, a gastroenterologist in Phoenix.

"Each physician has to query, if not interrogate, the Medicare beneficiary to find out what prescription drug plan he or she is on and then somehow determine what the appeal process is to get that beneficiary on a medication that's currently not covered," he said.

"With some plans, that information is very transparent. With others, you can only hope the beneficiary has a card somewhere with an 800 number or other information that a physician can use to track down how to file an appeal. It's very disconcerting."

CMS said the agency is aware of this potential disincentive for action and is working with the American Medical Association and other groups to develop a uniform request document that physicians and patients could use with any Medicare drug plan. But until they complete this process, doctors will need to check with each individual plan to see what is expected of them.

In anticipation of the end of transitional drug coverage and the potentially increased need for appeals information in the coming months, CMS has on its Web site a special fact sheet specially designed for physicians that outlines these processes.