Medicare Compliance & Reimbursement

Promoting generics when appropriate can help.

A new study suggests that helping physicians navigate Part D formularies may pay big dividends for community pharmacists.

Many times, doctors are still spinning their wheels trying to sort out plan formularies, say the authors of the study. That spells trouble for pharmacists, who wind up trying to help beneficiaries cope when they show up at the pharmacy with a prescription for a needed--but noncovered--drug.

The study, published June 20 in the Journal of the American Medical Association (Vol. 297, No. 23), reveals that docs have trouble finding out which prescription drugs are covered under any given patients' Part D prescription drug plan (PDP). Some time-strapped physicians make little effort to do the detective work.

Setting The Stage For Improvement

With a goal of helping clinicians identify appropriate drugs most likely to be covered, the researchers looked closely at formularies in two states, California and Hawaii.

Led by Dr. Chien-Wen Tseng of Honolulu's Pacific Research Health Institute, the team tracked 75 different prescription drugs within eight classes of drugs used for three common conditions (high blood pressure, cholesterol problems and depression). The classes studied were:

• ACE inhibitors for high blood pressure;
• ARBs (angiotensin II receptor blockers) for high blood pressure;
• Beta-blockers for high blood pressure;
• Calcium-channel blockers for high blood pressure;
• Loop diuretics for high blood pressure;
• Selective serotonin reuptake inhibitors (SSRIs) for depression;
• Statins for high cholesterol; and
• Thiazide diuretics for high blood pressure.

The researchers then determined the number of formularies with "widely covered" drugs in those eight drug classes--counting a drug as "widely covered" if it was included on at least 90 percent of plan formularies and with co-payments of $35 or less.

Key finding: Though the formularies varied substantially, all but one treatment class, the ARBs, had at least one widely covered drug at a low co-payment, according to the study.

Tip: Widely covered drugs tended to be generics, the study shows, though doctors can't assume that all generic drugs are widely covered or low in cost.

Ideally, physicians could discern more easily what various formularies cover, making certain that a patient headed to the pharmacy with a prescription that the PDP in question would cover.

"If this type of coverage information were made available in interactive fashion via a Web site, personal digital assistant-based tool, or e-prescribing software, clinicians could use this knowledge" in selecting medications for Medicare patients, the authors write.

Currently, physicians rely largely on formulary data on CMS' Part D Web site, which can be difficult to navigate.

"Pharmacists will continue to be key in communicating some of this information to physicians, but they are faced with some of the same problems accessing accurate formulary information," Tseng says.

In your quest to protect beneficiaries' interests and your bottom line, consider options you may have for providing paid medication therapy management services, coaches Dr. Brand Newland of Outcomes Pharmaceutical Health Care in Des Moines, IA.

"Pharmacists are well-positioned to serve this critical function, but the services they provide should not be free," coaches Newland. "With cost-focused conversations happening on a consistent basis in most community pharmacies, many find it a natural progression to begin providing standard cost-efficacy management services for eligible patients--and billing them."