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Table of Contents
Getting Started - The Basics
About Enrolling
Costs and Coverage
Problems Getting Your Drugs Under Your Plan
Other Common Problems / Changing Plans
Information for Medicare Providers
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Medicare Part D: The Prescriber's Role
BACKGROUND
On January 1, 2006, new prescription drug coverage under the Medicare program
will be available to your elderly and disabled patients.
This new prescription drug coverage is often called "Part D."
Part D will cover generic and brand name drugs.
Visit our section linking to
formulary drug lists and forms.
WHAT YOU SHOULD EXPECT
Your patients will ask you for general information about Part D.
Part D requires most elderly and disabled patients to enroll in a Part
D drug plan. As a trusted source, your patients will likely turn to you
for guidance regarding the new Part D benefit. You should encourage
your patients to learn more about Part D because it could save them money
on their prescriptions.
Furthermore, for patients with limited income and assets, extra
help will be provided for the costs associated with Part D.
When a patient asks you questions about Part D, you can refer them to
the following resources:
If the patient has access to the internet, tell them to visit
the Legal Services for the Elderly website at
www.mainelse.org, or
Find specific patient resources on our Part D Consumers site.
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Your patients will ask you for assistance when they cannot get a prescription
filled.
In most instances when a Part D plan refuses to cover a drug, your patient
WILL BE REQUIRED to submit a statement from you to the Part
D plan. This includes a Part D plan's denial of coverage because:
- The Part D plan determines that the drug is not medically necessary
- The drug is not on the Part D plan's formulary
- Prior authorization was not obtained from the Part D plan
- The prescribed form (liquid versus pill), or type (generic versus
brand) of drug, is not on the Part D plan's formulary
- The method of administration or dosage in not on the Part D plan's
formulary
- The patient cannot afford the drug
- The drug was removed from the formulary
Here's how you can help:
If you believe that there is a therapeutically equivalent medication
on the patient's formulary, you could write a new prescription.
OR
If you believe that the patient should take the medication you have
prescribed, the patient will need to request an Appeal.
| NOTE:
In order to make an Appeal, your patient must submit a statement from
you to the Part D plan. The Appeal will be rejected without your statement. |
Your statement must include the following:
- Diagnosis
- Reason why the prescription is medically necessary
- Additional information depending on the reason for the Part D plan's
denial. We have provided
Sample Physician Statements for most situations.
| NOTE: The plan
may take up to 72 hours to reach a decision on the Appeal.
If that is too long for the patient to wait, the plan must expedite
the decision-making process and reach a decision within 24 hours
if you call the plan and make the following statement:
"In my professional opinion, [Name of patient] must receive an
expedited decision in order to obtain [Name of drug] immediately. Failure
to issue an immediate decision will seriously jeopardize [name of patient's]
life or health or his/her ability to regain maximum function in that [state
the reasons]."
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Resources for Providers:
The Centers for Medicare & Medicaid Services website has extensive
Prescription
Drug Coverage Information for Providers.
Among the best is their
Toolkit for Health Professionals: Medicare Prescription
Drug Coverage, a PDF document.
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