Blogging Employee Benefits

February 27, 2006

Medicare Part D Draft CY 2007 Formulary Guidance

Filed under: CMS, Medicare Part D — Fuguerre @ 3:41 pm

Draft CY 2007 Formulary Guidance on Medicare Part D prescription drug policies is available for public comment. CMS will be accepting comment through March 6, 2006. Part D plan formulary submissions must be made between 3/27/2006 and 4/17/2006. [CMS Formulary Guidance Webpage]

Several of the items worth noting in the draft 2007 formulary guidance, as compared with the 2006 guidance

  • Certain Classes of Clinical Concern – The 2006 guidance required Part D plan formularies to include “all or substantially all” drugs in six particular classes: immunosuppressant, antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic. Under the draft 2007 guidance, formularies would be required to include substantially all drugs in those classes available on 4/17/2006, with subsequent new drugs to be subject to the normal P&T committee review process. The draft guidance lists four explicit exceptions not subject to the “substantially all” requirement. Restrictions on prior authorization or step therapy requirements for drugs within the six classes are prescribed. CMS further solicits industry feedback on current managed care strategies that might be implemented within the context of CMS policy.
  • Multiple Formularies – Multiple formularies that have been submitted by a plan should have meaningful differences, so that confusion among beneficiaries is reduced. CMS may request withdrawal of a formulary if no meaningful difference from the plan’s other formulary or formularies can be demonstrated.
  • Formulary Key Drug Types – If a USP Formulary Key Drug Type only includes drugs primarily covered under Part B, over-the-counter, statutorily excluded drugs, or drugs determined by the FDA to be less than effective, then the formulary need not include those drug types.
  • Specialty Tiers – CMS will approve formularies and plan designs that include a specialty tier only if certain conditions are met –
    • Single Specialty Tier – Only one tier may be designated a specialty tier exempt from cost-sharing exceptions.
    • 25% Cost-Sharing Ceiling – Cost-sharing for the initial range (or actuarially equivalent, for plans with decreased or no deductible basic alternative benefit design) associated with the specialty tier is limited to 25%.
    • $500 Monthly Price Floor – Only Part D drugs with plan negotiated prices that exceed $500 per month may be included in the specialty tier.

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