Medicare Part D: Transition, Prior Authorization,

1
Medicare Part D Transition, Prior Authorization,
Exceptions

• LIS PDPs MA-PD for Los Angeles County

2
Project Background

• Project Goals
• To provide a better understanding of the
  transition, exceptions prior authorization
  processes of Part D plans.
• To assist Medicare beneficiaries in obtaining
  coverage under these policies so that
  beneficiaries get appropriate and continuous care.

3
Survey Tool

• A survey was created with a list of questions
  regarding each plans transition, prior
  authorization exceptions policies.
• During the design of the survey, particular areas
  of interest were beneficiary notice, triggers,
  and terminology used by the plans.
• The survey tool was purposefully repetitive to
  capture inconsistencies in responses.

4
Data Collection

• April - May 2006 Plans were contacted and given
  written surveys to complete and return.
• May June 2006 Follow up conversations with
  plan contacts to confirm the information provided
  in the written survey responses and to obtain
  clarification of answers.
• June 2006 Verification of phone numbers and
  website addresses.
• This information is current as of June 12, 2006.

5
Plans Surveyed

• 10 Benchmark Part D PDP plans
• Blue Cross
• Unicare
• AARP
• United Healthcare
• Humana
• SierraRx
• Health Net Orange (2 plans)
• WellCare
• PacifiCare
• 2 MA-PD Plans
• Secure Horizons
• Kaiser

6
Key Trends

• Transition policies significant differences
  across plans.
• Prior Authorization Exceptions fairly
  standard across plans.
• Transition coverage one area of difference
  between LTC non-LTC beneficiaries.
• Physicians play the primary role in exceptions
  prior authorization request.
• Minimal beneficiary involvement is necessary.

7
Transition Coverage

• Transition coverage will continue to be important
  for new enrollees.
• Timeframe to access coverage
• Non-LTC First 30 days of enrollment
• LTC First 90 days of enrollment
• Must be a maintenance drug.
• Quantity limits apply.
• Wide variations among plans
• Different pharmacy protocols
• Different timeframes
• Different notification

8
Transition Coverage

• How do pharmacists know how to use transition
  coverage?
• Plans may not provide specific messaging when
  claims need to be submitted as transition fills.
• How do plans notify beneficiaries?
• Plans assume the pharmacist will notify the
  beneficiary.
• Majority of plans notify the member in writing.
• Transition fill will generally not trigger an
  exceptions request.

9
Prior Authorization

• Physician must submit request
• Minimal beneficiary involvement
• Time Frame
• Standard Review 72 hours
• Expedited Review 24 hours
• Timeframe begins when the plan receives the form
  and supporting documentation.
• CMS Model Form is accepted by all plans.

10
Prior Authorization

• Most requests are submitted via fax.
• Phone calls are preferred for expedited requests.
• Beneficiary Physician are both notified of
  decision.
• Beneficiary is notified in writing.
• Physician is notified by phone/fax.
• Some plans have drug-specific forms.
• Process does not differ for LTC residents.
• Kaiser does not utilize Prior Authorization.

11
Exceptions

• Exceptions requests are often referred to as
  Prior Authorization
• Physician must submit request.
• Minimal beneficiary involvement.
• Time Frame
• Standard Review 72 hours
• Expedited Review 24 hours
• Timeframe begins when the plan receives the form
  and supporting documentation.
• CMS Model Form is accepted by all plans.

12
Exceptions

• Most requests are submitted via fax.
• Phone calls are preferred for expedited requests.
• Beneficiary Physician are both notified of
  decision.
• Beneficiary is notified in writing.
• Physician is notified by phone/fax.
• Some plans have drug-specific forms.
• Although less common than with Prior
  Authorization.
• Process does not differ for LTC residents.

13
Prior Authorization ExceptionsThe Overlap

• Plans will refer to Exceptions as Prior
  Authorization.
• Can be difficult to determine what is being
  requested.
• Prior Authorization Exceptions are often
  identical processes.
• Plans will use the same form and review in the
  same manner.
• Notification does not differ.

14
Transition, Prior Authorization, Exceptions In
Practice

• Positives
• Prior Authorization Exceptions
• Prior Authorization requests are being resolved
  quickly.
• Potential problem areas
• Transition Coverage
• Notification of Beneficiaries.
• Assumptions about the role of pharmacists.
• Prior Authorization Exceptions
• Burden is on physicians.

15
Changes for 2007

• Transition Coverage
• 2007 CMS Transition guidance will require plans
  to provide at least one 30-day supply during the
  first 90 days of enrollment.
• 2007 CMS Transition Guidance states that plans
  will be required to send written notices to
  beneficiaries who receive a transition fill with
  in 3 business days.
• Prior Authorization Exceptions
• CMS has stated that plans must accept the CMS
  Model Form.