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Return to Expedite-Rx Home Page Funded Medicare Drug Benefit Update Tom Curb, R.Ph.
(In a continuing effort to provide timely information to Sponsors and members that may be affected by the pending 2006 funded Medicare Rx Benefit, I will pass on any information that may be of value in helping them make a decision about participation.) Excerpts from the "The Green Sheet" of weekly pharmacy reports reveal how Medicare PBMs’ restrictive formularies can be used to force enrollees to take drugs other than those proved effective for their maladies, or in the alternative, make enrollees pay much more toward the cost of their prescription(s) than the government has projected. From the government’s Centers for Medicare and Medicaid Services: "To address the needs of individuals who are stabilized on certain drug regimens, Part D plans are required to establish an appropriate transition process for new enrollees who are transitioning to Part D from other prescription drug coverage, and whose current drug therapies may not be included in their Part D formulary. (CMS said this in a March 16, 2005, information document on the Part D transition process.) As a general indicator, we (CMS) believe that a temporary ‘first fill’ supply of 30 days may reasonable for new enrollees who first present at a pharmacy with a prescription for a drug not on the formulary. The transition process applies to all Part D members, including new enrollees, beneficiaries who switch from one plan to another after implementation and dual eligibles who may be unaware of the impact of the prescription drug plan’s formulary or utilization management practices on their existing drug coverage." A review of the "formulary guidelines" for the Medicare program verifies that the PBMs’ allowable restrictive formularies may present a significant problem for those enrollees accustomed to a rich benefit and/or who take multiple medications. Because the Medicare PBMs will be competing for enrollees, it is obvious that formularies will not cover all medications, and since the PBMs will also be trying to maximize their profits - of which a portion will be from rebates for "preferred drugs" - they will limit enrollee choice in many drug categories to increase the preferred drugs’ market share. Members and/or benefits plans that are considering switching from their current drug benefit design to a Medicare program should investigate how restrictive formulary(ies) might increase plan or members’ costs or disrupt members’ "stabilized" therapies. Also, healthcare plans that are at risk for the medical expenses for their members should be aware as to how these product "switches" might adversely affect the health status of their members and thus their plan’s overall healthcare benefit costs.
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