Long Term Care: Medicare Prescription Drug Coverage in Institutions and Our Communities Larry Kocot Vanessa Duran

MMA Requirements regarding Access to Part D Drugs in LTC Facilities Section 1860D-4(b)(1)(C)(iv) of the Act requires convenient access to Part D drugs for residents of LTC facilities. Sec. 107 of the MMA requires a report to Congress: –Assessing the current standards of practice, clinical services, and other service requirements generally used for pharmacy services in long-term care settings –Evaluating the impact of those standards with respect to patient safety, reduction of medication errors and quality of care.

Regulatory Access Standards for LTC Pharmacies (§ (a)(5)) Plans must demonstrate convenient access to LTC pharmacies –Offer standard contracting terms & conditions to all I/T/U pharmacies in service area –Must contract with “any willing pharmacy” Standard terms and conditions must conform with certain performance and service criteria for the provision of LTC pharmacy services established by CMS in further guidance CMS has provided separate guidance regarding how convenient access to LTC pharmacies will be assessed

Regulatory Network Access Standards for LTC Pharmacies (§ (a)(5)) Anticipated benefits of our LTC access policy: –Plans may negotiate more competitive market rates with LTC pharmacies –LTC facilities will likely be able to select just one LTC pharmacy to serve their residents –May allow LTC facilities to negotiate more competitive rates for additional services for their residents from LTC pharmacies

LTC Guidance: LTC Pharmacy Performance and Service Criteria –Comprehensive inventory and inventory capacity –Pharmacy operations and prescription orders –Special packaging –IV medications –Compounding/alternative forms of drug compositions –Pharmacist on-call service –Delivery service –Emergency boxes –Emergency logbooks –Miscellaneous reports, forms, and prescription ordering supplies

LTC Guidance: Convenient Access Convenient access to LTC pharmacies for 2006: –Work plan –Performance and service criteria –Contracting with any willing pharmacy –Attestation of convenient access and list of network LTC pharmacies by August 1, 2005 Convenient access in future contract years may look at: –Enrollment/disenrollment rates –Complaints –Linking beneficiaries to LTC pharmacies to verify LTC pharmacy capacity

LTC Guidance: Formulary Plans must have a single formulary for all enrollees Plans must establish an appropriate transition process for new enrollees: –Procedures for medical review of non-formulary drugs –Procedures for switching enrollees to therapeutically equivalent alternatives failing affirmative medical necessity determination –Temporary one-time supply fills recommended –Documentation of range and circumstances impacting transition timeframes –Other transition methods (e.g., contacting enrollees in advance of initial effective date of enrollment)

LTC Guidance: Exceptions & Appeals We expect plans to consider interrelationship between LTC facility, LTC pharmacy, attending physician, and relevant laws and regulations in establishing grievance, coverage determination, and appeals processes Part D sponsors must clearly articulate financial responsibility of plans when Part D requirements and Medicare conditions of participation (COPs) conflict Recommend that plans consider one-time temporary or emergency supply process as a stopgap while an exception or appeal request is in process Regulations allow an appointed representative to act on an individual’s behalf