Doctors get new tool to cut Part D hassles

Washington -- Physicians anticipating a major administrative headache every time they want to prescribe a nonapproved drug to a Medicare beneficiary have one less thing to worry about.

The American Medical Association, in collaboration with Medicare drug plans and several physician and patient advocacy groups, has developed a master form that doctors can use to request coverage exceptions on behalf of their patients. The one-page document standardizes and streamlines the information that doctors must provide before they can go outside of a plan's drug formulary or obtain prior authorization for a nonpreferred drug.

The new tool will be a major time-saver for physicians who previously had to deal with multiple, lengthy request forms that differed from plan to plan, said AMA Trustee Edward L. Langston, MD, a family physician in Lafayette, Ind.

"Physicians consider multiple factors in selecting drug therapies for their patients in order to optimize benefits while minimizing problems like drug interactions, side effects and allergies. In order to avoid complications from changes in medication, physicians may need to seek exceptions for some patients," he said. "Physicians will now have a simple one-page form to easily communicate to drug plans why a patient needs a specific drug when other similar drugs are also covered by the plan."

The form includes areas for a doctor to give identifying information about the physician and beneficiary, the patient's medical diagnosis and recommended drug therapy, and the reason why the doctor believes a covered drug will be harmful or less effective.

The document specifies the supporting medical information that must accompany each request. For instance, a physician arguing that a chronically ill patient is stable only on his or her current medication regimen must explain why changing to a different drug would produce adverse clinical outcomes for the patient.

Physicians who need to order an expedited review of their coverage request simply can check a box to affirm that the patient's life, health or recovery would be in danger if they don't receive medication coverage right away. The plan then must make its decision within 24 hours instead of the usual 72-hour time frame.

America's Health Insurance Plans, which represents the insurers offering Medicare drug benefits, expects many of them immediately to begin incorporating the master form into their coverage determination process, said AHIP spokesman Mohit Ghose. In most cases, a plan simply needs to add its contact information and the company's logo before the document is ready for physician use.

The Centers for Medicare & Medicaid Services also has approved the form and will strongly encourage drug plans to offer it online, an agency spokesman said. CMS is offering a copy on its Web site, as is the AMA. This allows doctors who cannot find the plan-specific version to use the simplified request process as long as they can determine where to send it. Medicare is not now requiring plans to use the forms but might decide to issue such a mandate in the future.

The new tool comes at just the right time, the AMA's Dr. Langston said. March 31 marked the end of a special 90-day transitional drug coverage phase for beneficiaries. This was a period during which plans were required to cover enrollees' drugs even if the medications were not on the covered list. Now new enrollees can get a 30-day transitional supply of drugs before plans stop paying for noncovered medications.

Not a panacea

Although the form makes the first step in the process much easier, that doesn't mean doctors always will be happy with the ultimate outcome.

Physicians still may sometimes be required to do more administrative work if they want to keep their patients on noncovered or nonpreferred drugs.

For instance, certain plans could require more medical information beyond what is covered on the form when physicians request a certain type of exception, Ghose said. Certain biotech or other specialty drugs might need a separate form if a doctor is trying to get them covered.

Also, even though the initial coverage determination request has become easier, that doesn't mean physicians will receive approval more readily from the drug plans. If an insurer rejects a doctor's assertion that switching drug regimens would diminish efficacy or cause health problems, the doctor may need to go through up to five levels of appeal before receiving a favorable outcome -- if one is even forthcoming.

While the master form is certainly a good development, physicians still worry about how well the entire process will work for doctors and patients, said Joel Brill, MD, a Phoenix gastroenterologist. Differences between insurers in how they set up their benefits still could cause plenty of confusion and strife for physician practices, he said.

"This helps on the front end, but we're still left with some of the back-end problems of Part D," Dr. Brill said. "A drug that may be covered under one plan may not be covered under another plan, or it may be covered under a different benefit design structure. The appeal processes can also differ across the various prescription drug plans."