Medicare Appeals & Exceptions Process Ensures Seniors Have Coverage for All Medically Necessary Drugs

(Washington, DC)— The Pharmaceutical Care Management Association (PCMA) issued the following statement in response to an announcement from the Centers for Medicare & Medicaid Services (CMS) today regarding the end of transitional drug assistance for most beneficiaries enrolled in the Medicare prescription drug benefit:

“Medicare drug plans are committed to making sure seniors and disabled get the prescription drugs they need at an affordable cost.

“While the first 90 days of the program have presented challenges for certain groups of beneficiaries, Medicare drug plans have worked collaboratively with pharmacists, physicians, and the Medicare program to resolve these issues and provide beneficiaries coverage for the prescription drugs they rely upon. This collaborative effort has resulted in more than 27 million seniors now seeing expanded access and deeper-than-expected discounts on their prescription drugs.

“As the transition period comes to a close for most beneficiaries, it is important that all stakeholders build on this progress by working together to minimize â?? as much as possible â?? the inevitable challenges that arise during any transition period. Medicare drug plans have done their part to address early challenges and it is critical that other participants in the drug benefit do their part as well.

“In addition, PCMA believes it is critical that beneficiaries, clinicians, and others recognize the important role that pharmacy management tools â?? including multi-tier formularies, generics, and other techniques â?? play in promoting safety, improving quality, and reducing costs. In every other part of the health care system â?? including the Veterans Administration, Medicaid, Members of Congress’ own health plans, and private plans â?? pharmacy management tools are recognized as essential to improving outcomes and ensuring value-based purchasing.

“That’s why these same protections, coupled with extensive exceptions rules, are afforded to seniors and the disabled in the new Medicare drug benefit.”

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

Medicare Appeals & Exceptions Process Ensures Seniors Have Coverage for All Medically Necessary Drugs

(Washington, DC)—Contrary to recent press reports and assertions made today by Families USA, multi-tier formularies, increased use of generics, and other proven pharmacy management tools help improve quality and reduce costs for seniors in the new Medicare prescription drug benefit and, in tandem with Medicare’s appeals and exceptions process, ensure seniors get the drugs they need at an affordable cost, the Pharmaceutical Care Management Association (PCMA) said today.

“In every other part of the health care system, pharmacy management tools are recognized as essential to improving outcomes and ensuring value-based purchasing. That’s why these same protections, coupled with extensive appeals and exceptions rules, are afforded to seniors and the disabled in the new Medicare drug benefit,” said PCMA President Mark Merritt. “Regrettably, efforts to erode these proven tools would only harm seniors and turn back the clock to an unaccountable fee-for-service system with no regard to the real dangers associated with misuse, overuse, or underuse of prescription drugs.”

The pharmacy management tools that Medicare drug plans rely upon are similar to the same tools used by drug plans in Medicaid, Members of Congress’ own health plan, the Veterans Administration (VA), and private plans in the commercial marketplace. These tools, coupled with Medicare’s extensive appeals and exceptions rights, provide consumers with an array of quality and access protections.

Appeals & Exceptions Process in Medicare Prescription Drug Benefit

Under the Medicare Modernization Act, patients have the ability to receive coverage for any medically necessary drug, whether it is included on a plan formulary or not. If the drug is not included on a plan formulary, the patient can appeal to have the drug covered by their Medicare drug plan. Specifically:

· If the drug is not on a Medicare Advantage drug plan (MA) or a Medicare drug plan’s (PDP) formulary, the patient can appeal to their plan for coverage, based on a physician’s determination of medical necessity.

· Similarly, a patient may appeal a covered drug’s formulary placement to a lower cost-sharing tier.

· If the plan determines that a drug is not medically necessary or is in an appropriate formulary tier, the patient can appeal to an Independent Review Entity.

· If necessary, a patient can further request a hearing in front of an Administrative Law Judge and request a review by the Medicare Appeals Council. Medicare requires that appeals must be resolved within 72 hours for standard coverage determinations or within 24 hours in an emergency or life-threatening situation.

· Once the drug is determined through the appeal to be medically necessary, the plan must provide coverage for that drug.

Pharmacy management tools are also helping to drive down drug costs. Researchers at the Centers for Medicare and Medicaid Services recently announced that the rate of growth in prescription-drug spending slowed to a ten-year low, due in part to two tools used heavily by PBMs, increased use of generics and mail-service pharmacies. In Medicare, according to a recent PCMA analysis of the top 100 drugs used by seniors, Medicare beneficiaries are seeing discounts averaging 35 percent at retail pharmacies and 46 percent for medications dispensed through mail-service pharmacies.

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

(Washington, DC)— The Pharmaceutical Care Management Association (PCMA) issued the following statement in response to a new report issued today by the Institute for America’s Future, an arm of Americans United, which is a single-payer group that opposes providing seniors with more choice and competition in Medicare prescription drug benefit:

“Less than 90 days into the new Medicare prescription drug benefit, more than 25 million seniors are seeing expanded access and deep discounts on a wide range of prescription drugs. PCMA’s own analysis of the top 100 drugs seniors use has found that Medicare drug plans are saving beneficiaries an average of 35 percent on medications purchased at retail pharmacies and 46 percent on medications purchased through mail-service pharmacies.

“Despite this news, Americans United appears more intent on recycling the same tired arguments that a ‘one-size-fits all’ approach is the only way to expand coverage and lower drug costs for seniors. The Veterans’ Administration (VA) model they tout would result in fewer drug choices for seniors and result in a massive cost-shift to working families, small businesses, and Fortune 500 companies.

“The limited experience the federal government has in negotiating and administering drug benefits for small groups of beneficiaries is hardly encouraging. In Medicare Part B, the federal government overpaid physicians for oncology drugs and other physician-administered drugs by billions of dollars. With respect to Medicaid, the Office of Inspector of General has found that Medicaid overpaid pharmacies by 47 percent for Medicaid drugs. This record is hardly a model to replicate in the Medicare drug benefit.”

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

Same Tools Used in Members of Congress’ Own Health Plan

(Washington, DC)—A report issued today by the Minority Staff of the House Government Reform Committee confirms that seniors have wide access to the top 100 prescription drugs seniors rely upon, but fails to recognize the value of pharmacy management tools in promoting quality, expanding access, and controlling costs, the Pharmaceutical Care Management Association (PCMA) said today.

PCMA is the national association representing America’s pharmacy benefit managers (PBMs). PBMs administer prescription drug plans for more than 200 million Americans with health coverage provided through small businesses, Fortune 500 employers, health insurers, labor unions, and the Medicare program’s stand-alone prescription drug plans (PDPs) and Medicare Advantage plans.

“This new report from the minority staff of the House Government Reform Committee confirms that Medicare prescription drug plans are relying on these same pharmacy management tools that Members of Congress’ own health plan use to control costs while ensuring broad access to the drugs beneficiaries need,” said PCMA President Mark Merritt.

Mr. Merritt added, “Regrettably, the report ignores the value of pharmacy management tools. Pharmacy management tools have improved the quality of life for millions of Americans through better outcomes; saved billions of dollars for private and public purchasers; and made prescription drugs more affordable for working families.”

Pharmacy management tools such as prior authorization, step therapy, and quantity limits play a critical role in improving quality and constraining costs:

Prior Authorization (PA). When a drug is designated as subject to prior authorization on a plan’s formulary, it means that the plan must communicate with the prescribing physician about the particular patient’s diagnosis and whether there are alternative medications that may be more clinically appropriate. For those on maintenance medications used to treat chronic conditions, this process typically occurs only once and future refills are authorized typically without PA.

Step Therapy (ST). Step therapy is used to ensure that patients are prescribed first-line therapies for certain conditions before they utilize more powerful, more costly, and/or potentially more dangerous drugs. Drugs identified for step therapy require plan pre-approval prior to pharmacy dispensing. This generally involves communicating with the prescribing physician. If the first line therapy does not work, the patient should move to the second-line therapy, and so on. One large national PBM has estimated its clients can save 10 percent or more on overall drug spend when fully utilizing step therapy programs.
[1]

Quantity Limits (QL) . Quantity limits are often applied to certain medications to ensure proper prescription compliance by the patient. Drugs subject to quantity limits are often narcotics (i.e, Oxycontin), other drugs used primarily for sporadic or short-term use (i.e., Ambien) or so-called “lifestyle” drugs, though such limits may also be used more broadly. Overrides of drug quantity limitations do not typically require immediate physician intervention. Instead, patients fill their prescription for the allowable amount and the pharmacy/PBM will make a subsequent request for information from the physician to justify the override.

[1] Express Scripts, “2004 Drug Trend Report,” June 2005

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

‘Let’s Make Seniors the Priority’

(Washington, DC)—The Pharmaceutical Care Management Association (PCMA) today issued the following statement in response to a statement from the Association of Community Pharmacists Congressional Network. PCMA is the national association representing pharmacy benefit managers (PBMs), which administer prescription drug plans for more than 200 million Americans with health coverage provided through small businesses, Fortune 500 employers, health insurers, labor unions, and Medicare:

“Medicare prescription drug plans are increasing access and lowering drug costs for seniors and the disabled. A recent PCMA analysis found that Medicare prescription drug plans (PDPs) are providing seniors with meaningful discounts â?? an average of 35 percent savings for drugs purchased through retail pharmacies and 46 percent for prescriptions dispensed through mail-service pharmacies. Seniors would have otherwise paid much higher costs at drugstores prior to the new Medicare prescription drug benefit.

“Now is the time for drugstores, health plans, PBMs, and others to work together to encourage seniors to take advantage of the program, instead of playing the ‘blame game.’ The new Medicare drug benefit is trying to avoid the mistakes of the Medicaid program, particularly when it comes to paying too much for prescription drugs. The new benefit is good news for seniors and is something to embrace, rather than attack.”

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

(Washington, DC)— The Pharmaceutical Care Management Association (PCMA) issued the following statement in response to the Snowe-Wyden amendment approved today by the Senate that would require the federal government to negotiate drug prices in the Medicare prescription drug benefit:

“PCMA strongly believes that ‘direct negotiation’ of drug prices would hurt seniors, working families and small businesses. Requiring the federal government to directly negotiate prescription drug prices will take away drug choices for seniors and require massive cost-shifting to consumers and employers in the private marketplace.

“Proponents of ‘direct negotiation’ use the Veterans’ Administration (VA) drug plan as a model. However, a report from the U.S. General Accounting Office has noted that ‘mandating that federal prices for outpatient prescription drugs [such as the VA model] be extended to a large group of purchasers, such as Medicare beneficiaries, could lower the prices they pay, but raise prices for others.’

“The proven tools relied upon by pharmacy benefit managers (PBMs) and Medicare prescription drug plans (PDPs) have struck the right balance in managing costs while providing seniors with the prescription drugs they need. PCMA’s own analysis has found that PDPs are saving the Medicare program and beneficiaries an average of 35 percent on medications purchased at retail pharmacies and 46 percent on medications purchased through mail-service pharmacies.

“The Medicare drug benefit is working as Congress and the Administration intended, and is expanding access and driving down drug costs for seniors. Medicare drug plans and the Centers for Medicare & Medicaid Services are working hard to address the remaining challenges for certain groups of beneficiaries and are making progress everyday. Regrettably, Medicare ‘direct negotiation’ of drug prices would take us in the wrong direction by reducing seniors’ drug choices and shifting billions of dollars of costs to working families and small businesses.”
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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

Jacqueline Kosecoff, Ph.D., CEO, Appointed Ovations Pharmacy Solutions
PCMA Board Member

(Washington, DC) The Pharmaceutical Care Management Association (PCMA) is proud to announce that UnitedHealth Group is the associations newest Board-level member, the trade group said today.

With the completion of the merger of UnitedHealth Group and PacifiCare Health Systems in December 2005, UnitedHealthGroup now assumes PacifiCare Health Systems Prescription Solutions seat on the PCMA Board of Directors. Jacqueline Kosecoff, Ph.D., CEO of Ovations Pharmacy Solutions, is UnitedHealth Groups representative on the PCMA Board of Directors. Dr. Kosecoff previously represented Prescription Solutions on the PCMA Board.

“PCMA is proud to announce UnitedHealth Group as the associations newest member company,” said PCMA President Mark Merritt. “A true health care industry leader, UnitedHealth Groups participation in PCMA brings an important perspective to the associations advocacy efforts in Washington and in the states. PCMA is also very pleased that we will continue to have the benefit of Dr. Kosecoffs leadership on the Board of Directors. Dr. Kosecoff brings strong policy expertise, demonstrated executive leadership, and high energy to PCMA.”

“UnitedHealth Group looks forward to actively participating in PCMAs strategy development and advocacy efforts, “said UnitedHealth Groups Ovations Pharmacy Solutions CEO Jacqueline Kosecoff, Ph.D. “As the only national association focused exclusively on public policy issues associated with pharmacy benefit management, PCMA plays a pivotal role in implementing the new Medicare drug benefit while working to expand access to affordable, clinically effective prescription drugs for working families in the private market.”

PCMA is the national association representing Americas pharmacy benefit managers (PBMs). PBMs administer prescription drug plans for more than 200 million Americans with health coverage provided through small businesses, Fortune 500 employers, health insurers, labor unions, and the Medicare programs stand-alone prescription drug plans (PDPs) and Medicare Advantage plans.

UnitedHealth Group is a diversified health and well-being company dedicated to making health care work better. Headquartered in Minneapolis, Minn., UnitedHealth Group offers a broad spectrum of products and services through six operating businesses: UnitedHealthcare, Ovations, AmeriChoice, Uniprise, Specialized Care Services and Ingenix. Through its family of businesses, UnitedHealth Group serves approximately 65 million individuals nationwide.

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

Analysis Reinforces Savings Available through Increased Use of Generics

(Washington, DC)—An analysis released today by Consumers Union finding Medicare beneficiaries could save thousands of dollars on the cost of prescription drugs by choosing generic alternatives through their Medicare prescription drug plans only adds to the growing body of evidence about their cost-savings value and underscores the need for policymakers to expand access to generic drugs, the Pharmaceutical Care Management Association (PCMA) said today. PCMA is the national association representing America’s pharmacy benefit managers (PBMs).

Consumers Union’s new analysis, “Medicare Prescription Drug Benefit: Beneficiaries Can Lower Out-of-Pocket Costs While Getting Safe and Effective Drugs,” examined drugs from five commonly used drug categories used to treat high cholesterol, high-blood pressure, post-heart attack care, arthritis pain, and depression. The analysis found that Medicare beneficiaries choosing lower-cost generic alternatives could save between $2,300 and $5,000 per year on their prescription drug costs. In addition, the analysis found that beneficiaries choosing lower-cost generic alternatives could delay or eliminate the gap in Medicare Part D coverage known as the “doughnut hole.”

PCMA believes this latest analysis is more good news for Medicare beneficiaries and that these data are only the latest findings that highlight the cost-saving potential of clinically proven generic drugs:

In January, researchers from the Centers for Medicare & Medicaid Services found that prescription drug spending in 2004 slowed to its lowest growth rate in the past 10 years, rising 8.2 percent. Two of the chief reasons cited by CMS researchers for the slowdown in prescription drug spending were increased use of lower-cost generic drugs and mail-service pharmacies.
Last month, PCMA’s own analysis found seniors enrolled in Medicare prescription drug plans are seeing average savings on generic drugs ranging from 52 percent at retail pharmacies to 66 percent for generics dispensed through mail-service pharmacies. Generics typically cost 30 to 60 percent less than their brand-name counterparts.

These data also underscore the need for policymakers to work to expand access to generic drugs. Bipartisan legislation introduced recently by Senators Debbie Stabenow (D-Mich.) and Trent Lott (R-Miss.), “the Lower PRICED Drugs Act,” has the support of a broad group of organizations representing consumer and seniors’ groups, small businesses, Fortune 500 employers, health insurers, and PBMs.

This year, $11 billion in drug sales are expected to lose patents, with generic alternatives becoming available for at least 15 branded drugs. In total, over the next five years, an estimated $50 billion in brand-name drugs will lose patent exclusivity, providing further opportunities for greater cost savings for consumers and purchasers.

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605

(Washington, DC)—The Pharmaceutical Care Management Association (PCMA) today announced the appointment of Charles Coté as Director of Public Affairs. PCMA is the national association representing pharmacy benefit managers (PBMs), which administer prescription drug plans for more than 200 million Americans with health coverage provided through small businesses, Fortune 500 employers, health insurers, labor unions, and Medicare.

Mr. Coté brings a diverse background of strategic planning, communications, and legislative experience to PCMA. Prior to joining PCMA, Mr. Coté was a strategist at Spectrum Science Communications, a health-care exclusive communications firm based in Washington, DC. During his time at Spectrum, Mr. Coté was responsible for the execution of public affairs efforts for client interests at the state and federal levels on a variety of issues, including the Medicare prescription drug benefit, health centers, and medical technology. Mr. Coté also managed all aspects of the nationwide “Bob Dole on Medicare” educational campaign on the new Medicare prescription drug benefit while at Spectrum. Before arriving at Spectrum, Mr. Coté was Director of Communications for two gubernatorial campaigns in North Carolina. In addition, Mr. Coté has experience in broadcast journalism and also worked on Capitol Hill in the office of Congressman Dave Camp (MI-04).

“We are excited to have Charles join our team,” said PCMA President Mark Merritt. “The coming year will bring many challenges as PCMA works on behalf of working families, seniors, and small businesses to lower prescription drug costs and expand access. As Director of Public Affairs, Charles will help lead our efforts in Washington and in the states to highlight the real value of PBMs.”

Mr. Coté will report to Phil Blando, PCMA Vice President, Strategic Planning & Public Affairs.

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The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605