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Medicare's prescription drug benefit, also known as the Part D benefit, became effective on January 1, 2006. Although enrollment numbers for the benefit continue to rise, physicians and other health care providers still have questions about the benefit and its implementation. Here are some of the most common questions posed to ASCO's Coding & Reimbursement Hotline.
Question: Many of our patients have a Part D prescription drug plan. It is virtually impossible to know what each prescription plan covers. Are formularies for each plan publicly available somewhere?
Yes. Medicare created a tool, the Formulary Finder, that enables the beneficiary or the provider to access formularies for each plan. The Formulary Finder is available online at http://www.medicare.gov/MPDPF/Shared/Include/Formulary/FormularyFinder.asp?language=english.Providers can also download prescription drug plan (PDP) formularies at www.epocrates.com. Epocrates is a medical software company that has developed free downloadable software containing PDP formularies.
Question: There seems to be confusion with certain drugs, such as oral cancer drugs, when we write prescriptions for them. What does the confusion stem from?
Typically, drugs that are covered under Part B would be excluded from coverage under the Part D benefit. However, confusion exists with certain drugs that may be covered under Part B and/or Part D. The Centers for Medicare & Medicaid Services (CMS) has recommended that physicians include the diagnosis, the indication, and whether the drug is covered under Part B or Part D on written prescriptions for any potentially confusing drugs to clarify coverage. (See the sidebar for a list of drugs that may cause coverage confusion.)For example, an oral anticancer drug administered during chemotherapy that has the same active ingredient as the injectable version and used for the same indication as the injectable version, would be covered under Part B. If the provider wrote a prescription for an anticancer drug meeting these criteria, the drug would not be processed under the beneficiary's Part D benefit. However, if the oral anticancer drug did not have an injectable counterpart, the drug should be processed under the beneficiary's Part D benefit.Further information about Part B versus Part D coverage can be found on the CMS Web site at http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/01_Overview.asp#TopOfPage.
Question: Is each Part D plan required to have an exceptions and appeals process?
Yes, each Medicare Part D plan is required to have an exceptions and appeals process. The exceptions process would be initiated when an enrollee requests an exception to the plan's drug-tier structure, the waiving of a utilization requirement (such as dose restrictions or prior authorizations), or when an off-formulary drug is needed. When an enrollee requests a formulary or tiering exception, the physician must provide the plan with a supporting written or oral statement in support.There are multiple levels of an appeal process. Part D plans must communicate an initial coverage determination within 72 hours after receiving a standard request and 24 hours after receiving an expedited request. A re-determination can be requested of the plan, followed by reconsideration. Reconsiderations are handled by an independent review entity known as the Part D Qualified Independent Contractor (Part D QIC). Re-determinations and reconsiderations have time limits based on how the original coverage determination was requested (either standard or expedited). There is a 7-day time limit under the standard and a 72-hour limit under the expedited category.An appeal can continue after the Part D QIC on to an administrative law judge, then to the Medicare Appeals Council, and finally to a federal district court. However, CMS expects that most appeals will be resolved within the first two levels of the appeals process.
Question: We used to send our patients to the pharmacy and have the drug covered by the patient's Medicaid benefits. The Medicaid office informed us that they are no longer providing a pharmacy benefit. Is this true?
Yes. As of January 1, 2006, prescription drugs are covered under the Medicare Part D benefit. It is ASCO's understanding that, previously, some practices would write a prescription for chemotherapy drugs and have the dual-eligible patient (one with Medicare and Medicaid) go to the pharmacy to pick up the drugs. The drug charges were billed by the pharmacy, paid for under the patient's Medicaid pharmacy benefit, and the patient would bring the drugs back to the office for administration.However, as of January 1, 2006, all prescriptions are paid for under Medicare Part D. Therefore, if a physician has a dual-eligible patient pick up the drug from the pharmacy, the pharmacy will process the drug under the patient's Medicare Part D benefit.
Question: We are experiencing consistent problems with one plan in particular. Is there anyone we can discuss our concerns with?
Yes. CMS has identified an internal group, the Physician's Regulatory Initiatives Team (PRIT), to handle issues arising with prescription drug plans. Physicians and health care providers can send an e-mail tovog.shh.smc@TIRP. The e-mail should include the specifics of the problem, along with the plan name.Physicians and other health care providers are encouraged to participate in weekly conference calls with CMS to obtain updates and discuss issues related to Part D. Calls are held every Tuesday at 2:00 p.m. EST. The dial-in number is 800-619-2457, and the passcode is RBDML.
Question: The Part D benefit was effective January 1, 2006, but some of my patients still had not enrolled as of March 2006. Can they still enroll?
Yes. May 15, 2006 is the last day to enroll in a Medicare prescription drug plan to obtain coverage for 2006. If beneficiaries enroll after May 15, they may be subjected to a higher premium and a 1% penalty for each month they do not enroll. (Penalty does not apply to beneficiaries having other equivalent drug coverage.)Enrollment for prescription drug coverage in 2007 will be November 15 through December 31, 2006.
Question: My patient has Medicare and Medicaid and was enrolled in a prescription drug plan; however, the patient doesn't have a card. Is there a way to find out what plan the patient is enrolled in?
Yes. The patient can contact Medicare by calling 1-800-MEDICARE or by visiting the Medicare Web site at www.medicare.gov.
Question: If a patient enrolls in a plan in the middle of the month, when does the prescription drug benefit start?
If the beneficiary enrolls in a prescription drug plan at any time during the month, the effective date is the first day of the following month. For example, if a patient enrolled in a Part D plan March 20, 2006, the effective date would be April 1, 2006.Detailed information on Part D for providers and other health care professionals can be found on the CMS Web site at http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/01_Overview.asp#TopOfPage.Detailed information on Part D for beneficiaries and their families can be found on Medicare's Web site at www.medicare.gov.
For ASCO's Coding and Reimbursement Hotline, please call 703-299-1054 or send an e-mail togro.ocsa@ecitcarp.