Information for Medicare Providers

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Medicare Part D: The Prescriber's Role

Background

In 2006 new prescription drug coverage under Medicare became available to elderly and disabled people entitled to Medicare Part A or enrolled in Medicare Part B. Medicare Part D benefits are provided by numerous private insurance plans, each of which has its own Formulary, which changes every year and sometimes during the year. These Medicare Part D Plans are required to post their Formularies on line. Visit our links to Formularies and forms for many of the Medicare Part D Plans in Maine.

Patients with Limited Income

If your Medicare patients have limited incomes, they may be entitled to extra help with their prescription costs, through the Medicare Savings program, the Drugs for the Elderly program or full Maine Care. You could refer them to their local Area Agency on Aging (1-877-353-3771) or their local Department of Health and Human Services office for more information/help applying.

Prescriber’s Role in Getting Drugs Covered

Each Part D Plan has its own Formulary of medications it will cover. The Formularies all have various restrictions on certain medications, including Prior Authorization requirements, Step Therapy requirements, and Quantity Limits.

NOTE: Part D Plans are not allowed to deny coverage or impose restrictions for drugs in six specific classes, if a person was already stable on the drug when he/she enrolled in the Part D Plan. They can require that the generic, rather than the brand name, be used unless the prescriber states that the brand is medically necessary. These classes, referred to as the Six Classes of Clinical Concern, include immunosuppressants (for prophylaxis of organ transplant rejection), antidepressants, antipsychotics, anticonvulsants, antiretrovirals and antineoplastics.

If your patient needs a Medicare drug that does not fall within the Six Classes exception, and the prescribed medication is not on his/her Plan’s Formulary, or is on the Formulary but has a restriction on it, or in some cases if the co-pay is too high, your patient will need your help.

How you can help if the drug you prescribe is not on the Formulary, has a restriction or, in some cases, if the co-pay is too high:

If you believe there is a therapeutically equivalent medication on the patient’s Formulary, you could write a new prescription.

OR

If you believe that your patient needs the medication you prescribed (or needs the amount you prescribed if that exceeds the Plan’s Quantity Limits), your patient will need your help in filing a Coverage Determination request (sometimes called an Exception) with the Part D Plan.

Coverage Determination forms for many Maine Part D Plans can be found in our links to Formularies and forms.

Also, the CMS website has a standard form for coverage determinations under Medicare Part D, which can be used with all Part D plans, together with instructions for completing the form. In some cases, you can call the Part D Plan’s PA line and make your request over the phone.

You can also call LSE’s Medicare Part D Appeals Unit for help. (1-877-774-7772)

In filing a Coverage Determination request, you will need to provide the Plan with a diagnosis and a reason why the prescription is medically necessary. Also,

  • If the prescribed medication is not on the Plan’s Formulary, you will need to explain why your patient cannot take any of the medications that are on the Formulary, either because none would be as effective as the prescribed medication, or would have adverse effects, or both.
  • If there is a Prior Authorization requirement on the medication, you will need to address the Plan’s PA criteria. (The Part D Plans post the criteria on-line, or you can call the Plan.)
  • If there is a step therapy requirement, you will need to explain that your patient has tried and failed the step therapy drug(s), or explain why he/she should not start with those drugs (because they would not be as effective as the prescribed drug, or would have adverse effects.)
  • If there is a Quantity Limit restriction, and your prescription exceeds it, you will need to explain why your patient needs more than the quantity limit.
  • If you are trying to get your patient’s co-pay reduced, you are asking for a Tiering Exception and should write that on the form. You will need to state why your patient cannot take any of the cheaper medications on the Formulary, either because they would not be as effective as the drug you prescribed, or would have adverse effects, or both. (Tiering Exceptions are not available in all circumstances, including if the drug is on the Plan’s Specialty Tier.)
NOTE: Normally, a Part D Plan has 72 hours to issue a decision on a Coverage Determination. However, if you ask for an Expedited Decision and state that failure to issue an immediate decision will seriously jeopardize the patient’s life or health or his/her ability to regain maximum function, the Plan must issue a decision within 24 hours.

Appeals

If the Medicare Part D Plan denies your Coverage Determination request, your patient has the right to Appeal the denial, but must file the Appeal within 60 days of the denial. There are five levels of Appeal. The written Decision from the Part D Plan denying the Coverage Determination must contain instructions about how to Appeal. The Appeal will need to include a strong statement from you as to why your patient needs the medication (as discussed above.)

The Medicare Part D Unit of Legal Services for the Elderly can help your patients with the Appeals. 1-877-774-7772

Revised January 2014