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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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