CMS issues final drug rule

The Medicare drug regulation aims to improve formulary guidelines but makes no provision requiring network physician oversight of pharmacy and therapeutics committees.

By David Glendinning, AMNews staff. Feb. 14, 2005.

Washington -- Many doctors anticipate butting heads frequently with Medicare drug plans over what medications they will cover starting next year. But with the unveiling last month of the new benefit's final rule, physicians could find that this process goes a bit more smoothly than initially expected.

"The final Medicare rule on the prescription drug benefit addresses several concerns of the AMA," said American Medical Association President John C. Nelson, MD, MPH.

The Centers for Medicare & Medicaid Services' rule stresses the importance of allowing Medicare Part D beneficiaries and their doctors to challenge insurers when they believe drugs excluded from coverage are both vital to the patients' health and without adequate alternatives. CMS largely will allow plans to craft their own tiered drug formularies but will establish a system by which interested parties can ask for special coverage exceptions.

To improve this process, CMS has decided to shorten the time frame within which a plan must respond to a challenge. A doctor lodging a request to prescribe a noncovered or nonpreferred drug now will receive an answer within 72 hours, or within 24 hours if the doctor contends that the patient's condition warrants an expedited response.

Medicare officials say such tightened deadlines will ensure that seniors do not go without needed drugs while they wait for pharmaceutical benefit managers to make decisions. The proposed rule the agency issued in August 2004 would have given plans up to 14 days to respond to coverage challenges.