Medicare Part D: Transition, Prior Authorization, & Exceptions LIS PDPs & MA-PD for Los Angeles County 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Project Background 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Survey Tool 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Data Collection 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Plans Surveyed 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 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Key Trends 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Transition Coverage 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 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Transition Coverage 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Prior Authorization 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights 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. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights 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. 11/27/2018 Center for Health Care Rights

Prior Authorization & Exceptions: The 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. 11/27/2018 Center for Health Care Rights

Transition, Prior Authorization, & Exceptions In Practice 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. Burden is on physicians. 11/27/2018 Center for Health Care Rights

Center for Health Care Rights Changes for 2007 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. 11/27/2018 Center for Health Care Rights