Medicare Part D Update

Is Medicare Part D really working better or is it just that everyone has gotten so frustrated with it that they're not protesting anymore? That's a question the APA's Office of Healthcare Systems and Financing (OHSF) would like to have answered about the new prescription drug benefit.

According to Irvin L. "Sam" Muszynski, director of OHSF, "We've been able to get CMS [the Centers for Medicare and Medicaid Services, which oversees Medicare] to respond favorably with new guidelines to some of our concerns about patient access to psychiatric medications, and they've been willing to intervene on a case-by-case basis when we've communicated specific problems to them. We'd like them to tackle problems at a more systemic level or target companies that are not performing as they should, but we can't pressure them to act without reports from large numbers of prescribers supporting the need for this. We really need to hear from any members who continue to have problems getting their Medicare patients appropriate medications ."

Prior to Part D's debut in January 2006, the APA was very successful in getting CMS to identify antipsychotics, antidepressants, and anticonvulsants as three of the six classes of drugs of special interest under Part D. All drugs in these classes had to be included on each Part D prescription drug plan's (PDP's) formulary, instead of just the two drugs that were required for other drug classes. This designation has been carried over to 2007, and the 2007 transition guidance is an improvement over the 2006 guidance.

Since January, OHSF has been having ongoing, regularly scheduled calls with CMS staff, keeping them apprised of the problems the office has been hearing about through its designated Part D phoneline, 866-882-6227, and e-mail address, PartD@psych.org, and trying to work with them to get necessary changes made. According to Muszynski, a constructive relationship has developed, with CMS asking for help on mental health issues as well as OHSF asking CMS for assistance.

Unfortunately, CMS's apparent concern about access to psychiatric drugs has not kept the PDP's from finding ways to deny patients their medically necessary drugs, especially if those drugs are newer, brandname drugs. Although each prescription drug plan is a private insurer with its own formulary and set of rules, in most cases the more expensive drugs cannot be accessed without receiving prior authorization from the drug plan. And if the dosage of the brandname drug required exceeds the FDA-recommended dose, Muszynski reports that it is highly unlikely the prior authorization will be automatically granted. It may well be necessary to appeal the PDP's decision through several levels of appeal to obtain the necessary number of pills. OHSF has been actively involved in helping a number of physicians with successful appeals on their patients' behalf, and is available to assist with others.

OHSF is currently looking ahead November 15, when the six-week open enrollment season begins for 2007. Please contact OHSF if you are experiencing any problems with Part D by writing partd@psych.org or calling 866-882-6227. For information about Part D exceptions and appeals and the latest news, visit www.MentalHealthPartD.org.