Pharmacists To Review Proposed Formularies for New Medicare Prescription Drug Benefit, USA

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Pharmacy / Pharmacist
Article Date: 16 Mar 2005 - 9:00 PDT


As many as 145 clinical pharmacists will be available to review private plans' proposed formularies for the new Medicare prescription drug benefit during a monthlong work period starting April 18, Babette Edgar, director of the operations division at the... CMS Medicare Drug Benefit Group, said Monday, CQ HealthBeat reports. Insurers must submit by March 23 applications to offer the benefits, including Prescription Drug Plans, which will offer drug coverage under traditional fee-for-service Medicare, and Medicare Advantage Prescription Drug plans, which will offer coverage under Medicare's managed care program. Insurers' proposed formularies for the coverage will be due April 18. CMS reviewers -- including 20 agency pharmacists and an additional 125 pharmacists who will be on call -- then will evaluate the proposed formularies to ensure they meet 14 standards, Edgar said at a forum sponsored by the Kaiser Family Foundation. One standard will be whether the plans cover the categories of drugs specified by the United States Pharmacopeial Convention or alternative categories that meet a variety of criteria. Edgar said plans will have to cover "substantially all, if not all," drugs in a number of categories -- including mental health, HIV/AIDS, immunosuppressant medications, cancer, and anti-convulsants -- and that CMS will make sure that certain key drugs are not subject to "tiers" of unaffordable cost sharing, according to CQ HealthBeat. According to Edgar, CMS hopes to complete the checks within two weeks and then spend another two weeks negotiating changes to the formularies with plan sponsors. CMS is scheduled to notify plan sponsors whether it will accept or reject the proposed formularies by May 18. Evaluations of whether plans have adequate transition systems for beneficiaries dually eligible for Medicare and Medicaid will be completed separately by early June, according to Edgar (CQ HealthBeat, 3/14).

EMTALA Advisory Committee
In related news, CMS on Monday announced the creation of an advisory group that will review regulations affecting provider responsibilities under the Emergency Medical Treatment and Labor Act. EMTALA, enacted by Congress in 1986, requires hospitals and emergency departments to screen all individuals who request medical treatment and either stabilize or transfer the patient if a medical condition is detected. The advisory group, which was required by the new Medicare law, is charged with helping CMS develop rules to protect individual rights while minimizing burdens on providers, according to CMS. The group, which will meet at least twice annually, has 19 members, including CMS Administrator Mark McClellan. The first meeting is scheduled for March 30 and 31 (CQ HealthBeat, 3/14).

Pay for Performance
Although the proposed fiscal year 2005-2006 budget does not call for updating fees to physicians or incorporating pay-for-performance elements into the Medicare payment structure, lawmakers reportedly are planning efforts to do so, CongressDaily reports. Currently, calls for spending cuts that largely affect Medicaid threaten to derail an effort to turn a scheduled 5% payment cut to physicians into a 1.5% increase for 2006. Senate Finance Committee Chair Chuck Grassley (R-Iowa) said he plans to propose a fee change that likely would include pay-for-performance elements even without the appropriate allocation from the committee. He added, however, that he will hold off on introducing the proposal in hopes that physicians groups will propose a reimbursement formula that lawmakers will approve. Meanwhile, House Ways and Means Health Subcommittee Chair Nancy Johnson (R-Conn.) also said pay for performance will be part of a reimbursement update (Heil, CongressDaily, 3/14).

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