Easing the Part D burden: A new tool will help

A one-page form makes it easier for physicians to seek exceptions to Medicare drug plans' formulary rules.

Posted May 8, 2006.

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In health care matters, both clinical and beyond, patients look to their physicians as trusted advisers. Medicare Part D is a case in point.

Beneficiaries have been confused about this new outpatient prescription drug benefit since enrollment began last November. In a February Kaiser Family Foundation survey of seniors, 61% said they understood Part D "not too well" or "not at all."

Many are overwhelmed by the number of drug plan options. Seniors are struggling to figure out how much the different choices cost and whether their medications will be covered. They are dismayed when a drug they need is not in their plan's formulary.

So these patients turn to their doctors for help. The Kaiser survey found that 26% talked to their physician about the new benefit, and 61% said they trust their doctor to help them understand and choose among Medicare drug plans.

As the May 15 deadline for current beneficiaries to enroll in a plan nears, expect questions and serious concern from seniors to continue, if not increase.

Fortunately for doctors, there are resources that can help them assist patients from a clinical standpoint and on Medicare Part D in general.

The latest is a new tool developed by the American Medical Association, along with many working group partners and the trade group America's Health Insurance Plans. It is a one-page form designed to streamline the process by which doctors request prior authorizations and exceptions to plan formularies for particular patients.

Previously, physicians had to deal with different forms from the various plans, each with its own set of instructions for doctors to justify why a patient needs a drug not on the formulary. This process was cumbersome and time consuming.

The AMA, health plans and the Centers for Medicare & Medicaid Services are working together to roll out widespread use of the new form, unveiled April 11. The document is found on these organizations' Web sites. CMS is strongly urging plans to use the form and wants to hear from physicians if insurers aren't doing so.

Plans' adoption of this tool will cut physicians' paperwork hassles and help seniors get needed drugs more quickly.

The move was particularly timely. March 31 marked the last day of a 90-day transition period in which the government required health plans to continue providing coverage for nonformulary drugs. (For enrollees who sign up for a drug plan after March 31, drug plans must provide a 30-day transitional supply of beneficiaries' drugs before ending coverage for medications not on their formularies.)

For medical reasons, however, some beneficiaries will need to take drugs their health plan doesn't cover at all or covers at a higher cost or with certain stipulations. Now that the extended transition period is over, doctors need to help patients get exceptions to the rules using this form so they can continue their medication regimens.

Many Medicare patients have multiple chronic conditions, and 46% are taking five or more prescription drugs, the AMA noted in announcing the new form. In these complicated cases, doctors and patients have worked out regimens that avoid adverse drug interactions, side effects and allergies while maximizing health benefits. Any change could knock the delicate balance out of whack. These patients in particular can benefit from formulary exceptions.

The new form is just the latest effort of the working group, which besides the AMA includes the American Psychiatric Assn., the American Academy of Family Physicians, the American College of Physicians and the Medical Group Management Assn.

Earlier this year, the group created a form pharmacists can use to tell physicians of problems with drug plan coverage policies and to let doctors know if other medications are available to lower patient costs. This document is also available on the Web pages of CMS and the organizations involved.

Other brochures, information and resources that doctors can use to help their patients sort out Medicare Part D can be found at the AMA's Web site.

Armed with this information and these resources, doctors will be able both to advise their patients and to help ensure that their access to needed medication is preserved.

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External links

AMA information, including the new drug exceptions and prior authorizations form, doctors can use to help patients with Medicare Part D (link)

Centers for Medicare & Medicaid Services on Medicare prescription drug coverage (link)

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