Part D Formularies Expected to Cover Most Psychiatric Medications

Prescription drug plan (PDP) formularies under the new Medicare Part D program appear to cover all medications relevant to the treatment of mental illness, including substance abuse, according to a preliminary review of the plans by APA's Office of Health Systems and Financing.

But still there are many bugs in the system that the government has provided for ascertaining more detailed information about the availability of varying dosages, and the kind of restrictions—such as prior authorization or requirements for step therapy—that may apply.

At press time, Irvin Muszynski, J.D., director of APA's Office of Healthcare Systems and Financing, told Psychiatric News that the Formulary Finder—the online tool provided by the government at the Medicare Web site<www.medicare.gov>—appears to be deficient.

And Web pages offered by sponsoring PDPs also do not appear to provide sufficient information, he said.

“For us to help physicians and patients make informed decisions about the plans, we need a laundry list of information about plan formularies, including exactly what drugs are included, what restrictions may apply, and related details,” Muszynski said. “But when you go to the formulary finder or to a sponsoring plan's homepage, you simply cannot extract all the data elements to provide informed decision support.”

A letter from APA to Mark McClellan, M.D., M.P.H., administrator of the Centers for Medicare and Medicaid Services (CMS), outlined concerns about the formulary finder.

In the meantime, Muszynski said the medications most relevant to patients with mental illness and substance abuse appear to be covered. “The plans seem to be relatively inclusive of all the relevant drugs,” he said.“ What we don't know is whether all dosages and all forms of a drug are available or where quantity limits, prior authorization, or step therapy is indicated.”

In the weeks leading up to marketing of PDPs, APA and other advocacy organizations were bracing for potential problems concerning enrollment of“ dual eligibles” (individuals who qualify for both Medicare and Medicaid), formulary restrictions, and copayments and deductibles associated with the complex new benefit (Psychiatric News, October 7).

More recently, some of those concerns have abated as it appears that the government has made good on its promise that “all or substantially all” medications necessary for the treatment of mental illness, including substance abuse, are included in plan formularies.

At APA's Institute on Psychiatric Services last month, Jeffrey Kelman, M.D., M.M.Sc., chief medical officer at the Center for Beneficiary Services of the CMS, told psychiatrists that “the formularies are much more robust than we had expected, and no class of disease or drug is discriminated against.”

Moreover, Kelman said that psychiatrists should expect minimal problems with processing appeals and requests for exceptions to the formularies. He noted that the population requiring antipsychotic drugs, for instance, would be a small part of most PDPs' business and that the expensive and time-consuming process of appeals would make it unlikely that they would put up much resistance. (Psychiatric News, November 4).

Muszynski expressed confidence in the good faith of CMS to rectify problems with the Formulary Finder and with the formularies themselves. “We are just anxious to verify what looks to be a relatively inclusive set of formularies,” he said.

More information on Part D from APA and its partners is posted at<www.mentalhealthpartd.org/>.▪