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Medicare Part D: Transition, Prior Authorization, & Exceptions. LIS PDPs & MA-PD for Los Angeles County . Project Background. Project Goals: To provide a better understanding of the transition, exceptions & prior authorization processes of Part D plans.

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Medicare part d transition prior authorization exceptions

Medicare Part D: Transition, Prior Authorization, & Exceptions

LIS PDPs & MA-PD for Los Angeles County

Center for Health Care Rights


Project background
Project Background Exceptions

  • 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


Survey tool
Survey Tool Exceptions

  • 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


Data collection
Data Collection Exceptions

  • 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


Plans surveyed
Plans Surveyed Exceptions

  • 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


Key trends
Key Trends Exceptions

  • 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


Transition coverage
Transition Coverage Exceptions

  • 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


Transition coverage1
Transition Coverage Exceptions

  • 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


Prior authorization
Prior Authorization Exceptions

  • 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


Prior authorization1
Prior Authorization 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.

  • Process does not differ for LTC residents.

  • Kaiser does not utilize Prior Authorization.

Center for Health Care Rights


Exceptions
Exceptions 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


Exceptions1
Exceptions 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


Prior authorization exceptions the overlap
Prior Authorization & Exceptions: 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.

Center for Health Care Rights


Transition prior authorization exceptions in practice
Transition, Prior Authorization, & Exceptions In Practice Exceptions

  • 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


Changes for 2007
Changes for 2007 Exceptions

  • 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


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