| Medicare-Medicaid
Index|HealthChoices
General Information Fact Sheet | Voluntary
Managed Care Fact Sheet | ACCESS
Plus Fact Sheet |
Statewide
Managed Care Map
| Medicare
Part D Brochure, NAMI National
|
Medicare Changes for 2007
Medicare
Part D- Prescription Drug Assistance
and Medical Assistance (Medicaid) in Pennsylvania
Medicare Part D 2007 Formulary Changes
(New Medicare Prescription Drug Coverage As of October 2006)
Print
Version
In 2007, Medicare is continuing to ensure that people
with Medicare Prescription Drug Coverage can get the prescription
drugs they need. Medicare reviews every Part D plan’s formulary
and any subsequent changes to that formulary. If a person with Medicare
is taking a Part D drug that is not on the plan’s formulary,
a required transition period allows the person to get a temporary
supply of the drug, while they arrange for an alternate prescription
or ask for an exception.
How will Part D plan formularies change in
2007?
In 2007, people with Medicare will have greater access than ever
before to the prescription drugs they need. Medicare compared the
Part D plan formularies from 2006 to those being offered in 2007,
and found the following results.
Stand alone Prescription Drug Plans (PDPs):
• At least a 13 percent increase, on average,
in the number of items (reference NDCs) on formularies (plan level,
unweighted analysis)
• A slight decrease, on average, in the percentage of formulary
items with quantity limit restrictions
• No change in prior authorization rates
• A small increase in the percentage of items that require
step therapy Medicare Advantage Prescription Drug (MA-PD) Plans
• A greater than 10 percent increase on average, in the
number of items (reference NDCs) on formularies (plan level, unweighted
analysis)
• No change, on average, in the rates of prior authorization
and quantity limits
• A slight increase in the rate of step therapy
What do the formularies show about the drugs
seniors use most?
For the 2007 and 2006 formularies, Medicare compared the top 100
drugs that seniors use, in the top 10 enrollment plans in each PDP
region. Medicare found that:
• For the stand-alone PDPs, there is an average
increase of around 8 percent in the number of these top drugs
on the formularies.
• For these top drugs in these top PDP plans, there was
a small decrease in the number of drugs requiring prior authorization,
and an increase in the drugs requiring step therapy and quantity
limits.
• For the top 10 MA-PD enrollment plans in each region (i.e.,
within the states included in the defined PDP regions), there
is an average increase of approximately 6 percent in the number
of these top drugs on the formularies.
• For the top drugs in these MA-PD plans, there are slight
increases in step therapy, prior authorization, and quantity limit
requirements.
What is Utilization Management?
Utilization management includes special requirements like prior
authorization, step therapy or quantity limits to better manage
how prescription drugs are provided to people in the plan. Utilization
management tools like these were used in 2006 Medicare Part D plan
formularies and is common in commercial (private-sector) drug plans.
Medicare reviews the utilization management requirements in each
plan’s formulary to make sure they are appropriate.
Why is utilization management important?
These tools can protect people with Medicare and keep them safe.
In 2007, prior authorization requirements were often added to drugs
that may have safety concerns, especially for people with Medicare,
such as amphetamine-type central nervous system stimulants. Some
plans commonly added step-therapy requirements to drugs to encourage
people to try proven, cost-effective drugs first. Some plans added
quantity limits to some drugs with safety concerns to make sure
they are used in safe, recommended doses. For example, prescription
drugs used to treat some mental health conditions commonly have
quantity limitations that are consistent with FDA-approved labeling.
Others include drugs that could be abused or overused, such as drugs
to treat severe pain. The utilization management tools also are
often necessary to bill Medicare correctly. For example, some Part
D plans added prior authorization in 2007 to drugs, such as total
parental nutrition (TPN) products, that could be covered under Medicare
Part B depending on the use and/or setting.
What transition help is available to people
who are affected by formulary changes?
People with Medicare who are affected by formulary changes from
2006 to 2007 can make use of their plans’ transition processes
or request exceptions. Transition processes are in place for the
following:
• New plan enrollees starting on January 1, 2007
• Enrollees who are newly-eligible to Medicare joining a plan
anytime in 2007
• People who transfer from other Part D plans (e.g., full
benefit dual eligible) joining anytime in 2007.
Plans may also provide transition processes for current
enrollees who are affected negatively by formulary changes between
2006 and 2007. In general, these processes apply to non-formulary
drugs and those drugs beneficiaries have accessed through the exceptions
process in 2006. Transition supplies make sure that a person enrolled
in the plan can get a temporary fill of the prescription they need.
Plans will also send a transition notice to the enrollee within
3 business days of filling a transition supply. This notice will
include directions for finding a therapeutic equivalent drug that
is on the formulary and a description of the steps to take to file
a formulary exception.
|
