Medicare Part D: Transition, Prior Authorization, & Exceptions

1. Medicare Part D: Transition, Prior Authorization, & Exceptions LIS PDPs & MA-PD for Los Angeles County Center for Health Care Rights

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. Center for Health Care Rights

3. Survey Tool • A survey was created with a list of questions regarding each plan’s 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. Center for Health Care Rights

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. Center for Health Care Rights

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 Center for Health Care Rights

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. Center for Health Care Rights

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 Center for Health Care Rights

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. Center for Health Care Rights

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. Center for Health Care Rights

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. Center for Health Care Rights

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. Center for Health Care Rights

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. Center for Health Care Rights

13. Prior Authorization & Exceptions:The 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. Center for Health Care Rights

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. Center for Health Care Rights

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. Center for Health Care Rights