Psychiatric Practice and Managed Care APA Office of Healthcare Systemsand Financing
Part D Alert: Plan Ahead
Psychiatric News
Volume 41 Number 21 page 19-19

Medicare's Part D prescription drug benefit begins its open enrollment period for 2007 on November 15. By the end of October, current enrollees should have received an Annual Notice of Change (ANOC) document from their 2006 plan. This document points out any changes in the plan's formulary or procedures for 2007.

The ANOC is not specific to each enrollee, so patients are advised to read the entire document to determine whether there are changes that will affect them.

Still in effect is the Centers for Medicare and Medicaid Services' (CMS) policy that “all or substantially all” antidepressants, antipsychotics, and anticonvulsants (three of the six “classes of clinical concern”) must be included in plan formularies for 2007. In discussions with APA staff, CMS officials have made it clear that psychiatric patients should be able to continue taking the medications on which they have been stabilized. CMS has also strengthened the transition policy from plan to plan, so that compared with last January, fewer patients should encounter problems when they try to get prescriptions from their pharmacy at the start of 2007.

Nonetheless, APA's Office of Healthcare Systems and Financing (OHSF) is very concerned that prior authorizations and exceptions to plan formularies achieved in 2006 through the appeals process will, in most cases, be terminated automatically at the end of the plan year. Irvin (Sam) Muszynski, J.D., director of OHSF, has suggested to CMS that a form be developed so that exceptions for patients who have had no change in their conditions could continue into the next year without a hitch.

Muszynski said, “A simple form on which the prescribing physician certifies that the patient continues to need the medication that was found medically necessary in the previous year should suffice, but we haven't yet heard back from CMS about whether this will be implemented. We urge APA members to continue contacting us about this and any other problems they're having with Part D so that we will be able to continue having fruitful negotiations with CMS.”

If any of your Medicare patients obtained their Part D drugs only on the basis of prior authorizations or appeals and are not changing plans, you should remind them that this process may have to be reinstituted the first time they need their prescriptions refilled in 2007. Some drug plans may have granted open-ended prior authorizations and exceptions, but most likely the documentation they provided when the prior authorization or exception was granted stipulated the period for which the prior authorization or exception was effective. You may be able to begin the process now for next year to avoid lapses in coverage.

Patients who change plans must begin the authorization process again if their new plan does not have all of their needed drugs on the formulary.

You can send OHSF your Part D questions or problems by e-mail to PartD@psych.org or by phone to (866) 882-6227. Check out<www.MentalHealthPartD.org> for the latest updates and pertinent information on Part D for psychiatrists and their patients.

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