Long-Term Care Survey Alert

Published on Sat May 28, 2005 PDF

Beware: Residents could fall through the formulary without the right assistance.

Medicare Part D poses one of those good news, bad news scenarios for facilities and residents - one that an astute medical director can tip in the former direction.

Under the Medicare Part D prescription drug benefit, effective Jan. 1, 2006, residents with the coverage will have access to payment for medications. Yet drugs that aren't on the resident's Part D formulary won't be covered - unless the plan administering the coverage grants an exception, observes Robert Hill, an attorney with Reed Smith in Washington, DC.

"Part D plans will be required to have a transition process for their enrollees currently taking non-formulary medications, which will presumably involve the plan asking the prescribing physician to switch the prescription to a drug on the plan's formulary," Hill tells Eli.

The challenge: Requests for exceptions to a plan's formulary will generally require the prescribing physician to provide a supporting statement giving the reasons why none of the drugs on the plan's formulary would be medically appropriate for the patient. "Medical directors can play an important role in helping to ensure that this process goes smoothly - and that resident care does not suffer," Hill suggests.

Read the Centers for Medicare & Medicaid Services' guidance to help Medicare Part D plans formulate policies for pharmacies providing services and products to residents in nursing homes (www.ascp.com/medicarerx/docs/LTC_guidance.pdf).