Since 1908

Updated 10/8/08

Overview

 MPS helping you to get a grip on the Medicare Prescription Drug Benefit

The Medicare Modernization Act of 2003 (MMA) created a new voluntary outpatient prescription drug benefit called “Part D” or “Medicare Prescription Drug Coverage.”  This offers a good deal for Medicare beneficiaries who have not had a drug benefit before.  However, drugs that patients require may be subject to utilization management tools, such as prior authorization, that will be employed by the Prescription Drug Plans (PDPs).

There is encouraging news: the Center for Medicare & Medicaid Services (CMS) recently issued a guidance to bidding sponsors of PDPs indicating the expectation that all drugs in six selected categories, including antidepressant, antipsychotic and anticonvulsant categories, should be included on a formulary, with certain exceptions.

MPS remains concerned, especially for the 200,000 Medicare/Medicaid dual eligible beneficiaries¹ in Michigan, many of whom may or may not be seniors and are eligible due to a psychiatric or other disability.  These beneficiaries, many with complex or chronic conditions, will be losing broad access to prescription drugs under the Michigan Medicaid provided pharmacy benefit on January 1, 2006.  Dual eligibles are expected to choose during a six-week period, among available PDPs, which will offer various formularies and may not cover all the drugs they need.

We are also analyzing the procedures and the amount of physician effort that may be needed to request authorizations or exceptions or to appeal adverse drug plan coverage decisions. MPS will help Michigan psychiatrists with information on the benefit and to sort out unfolding developments.

Part D topics and links:

• About the drug benefit
• The Timetable
• Patients’ eligibility for subsidy or “extra help”
• Enrollment in a Plan
• Outreach
• Cost-sharing requirements
• The Prescription Drug Plans (PDPs)
• Formulary issues and exclusions
• Transition for dual eligibles
• Exceptions and appeals procedures
• Help for your patients
• Links to Resources

For a full overview in pdf format click here

¹Full-benefit dual eligible individuals are those low-income seniors and eligible people with disabilities, who are enrolled in both Medicaid and Medicare, and who currently receive Medicaid covered prescription drugs, nursing home and other long-term care and health care services not currently covered by Medicare.  In addition, Medicaid pays for Medicare premiums and cost sharing for full-benefit dual eligibles. This information piece refers to these full-benefit dual eligible individuals as “dual eligibles.”