Formulary friction: Doctors fear prescription limits

The new Medicare drug benefit starts in 2006. Physicians are working now to make sure that enough drugs make the list and that the hassle factor is low.

By David Glendinning, AMNews staff. Dec. 6, 2004.

Doctors are eager for Medicare to start covering the outpatient drugs they prescribe. But that enthusiasm is tempered by fears that the new benefit now receiving its finishing touches from federal regulators will be far too restrictive.

Physicians soon could encounter a system in which tightly controlled drug formularies leave them with too few drug options for patients who are elderly and have disabilities, says the American Medical Association. Any attempt to get a plan to pay for an excluded medication could be such a hassle that doctors simply decide they don't have the time or resources to go through with it.

Such concerns are at the heart of the AMA comments on the Centers for Medicare & Medicaid Services' proposed drug benefit rule. After reviewing comments from all stakeholders, the agency hopes to unveil final regulations for implementing the new program, called Medicare Part D, in early January, said Patricia Smith, director of CMS' Medicare Advantage Group. The drug benefit will begin in 2006.

Part of the perceived problem is that federal officials aren't saying much right now about formularies. They are opting instead to give authorized prescription drug plans the freedom to set up their own lists of covered drugs. These plans can choose to incorporate model guidelines from the U.S. Pharmacopeial Convention or develop their own, as long as the final product meets CMS specifications by not excluding vital drugs in a way that discriminates against any class of patient.