Friday, October 21, 2005

About Medicare Part D Formularies

I'm still looking for some handy dandy list of the formularies for the various pharmacy providers for the new Medicare Part D prescription drug benefit. So far, the best I have found is a list of providers and a tool for searching for specific drugs. Both are good things to have around, but not exactly what I want so that I can say "This plan has a full range of HIV meds; this one not so much."

What I did run across was Medicare's position paper (PDF) on what should be in a formulary.

Why is CMS requiring “all or substantially all” of the drugs in the antidepressant, antipsychotic, anticonvulsant, anticancer, immunosuppressant and HIV/AIDS categories?

CMS has a responsibility under the Medicare Modernization Act (MMA) to make sure beneficiaries receive clinically appropriate medications so that formularies are not discriminatory. In our final formulary guidance for 2006, we noted that a majority of drugs in these categories would have to be on plan formularies and that beneficiaries should have uninterrupted access to all drugs in that class. In addition, our formulary guidance explicitly stated that we would encourage the use of formularies that have been demonstrated to be effective by their widespread use today for millions of seniors and people with disabilities. In the process of reviewing the practices of other Federal programs for comparable populations such as the Federal Employees Health Benefit Program (FEHB) and Medicaid, we learned that formulary inclusion rather than an exceptions process is an appropriate standard in certain circumstances.

The remainder of the paper elaborates on each of those points and discusses HIV/AIDS treatments quite specifically, asserting that there should be no interruption in therapy. On its surface, this should mean that almost all of the plans available for Texas should have what people need for HAART, and there shouldn't be any hassles with prior authorization and such.

However, there are a couple of caveats already apparent. Fuzeon was specifically singled out as being required for a plan's formulary, but it was also allowed to be set for prior authorization. There was also some mention of drugs that will not have been approved by the FDA prior to January 1, 2006, having to go through a formal review process for inclusion on a plan's formulary. And there was an indication that the requirements regarding HIV/AIDS drugs and the others covered by this paper would be reviewed once experience with the program had been gained. All of these are indicators that, at the very least, Medicare requirements will continue to need monitoring.

But I'm still looking for a spreadsheet . . .


The Advocacy Project said...

This Medicare situation is extremely difficult for the community and was not well thought out.

Carolyn said...

It does look that way, TAP. I am hopeful that the Texas HIV Medication Program will have some helpful information available in its upcoming community meetings and on its website. In the meantime, if you'll let us know of any specific problems that you have, we can try to get you some answers.