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Medicare Drug Benefit Update:  CMS Renews Critical Beneficiary Protections for 2007, Drug Plans Must Continue to Offer Broad Coverage of Medications to Treat Mental Illness

March 9, 2006

Last week the federal Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for Medicare, issued guidelines that renew protections that require drug plans to offer broad coverage of psychotropic medications and cover all prescriptions of new plan enrollees.  These protections are currently in place and will be renewed through 2008.

Renewal of Formulary Guidance

The guidance that CMS renewed for 2007 requires Medicare drug plans to cover "all or substantially all" medications in six therapeutic categories including anti-psychotics, antidepressants, and anticonvulsants.  This guidance was set forth last year for the initial year of the program and will now stay in effect for the 2007 plan year.  This means that Medicare drug plans will not be able to completely exclude medications to treat mental illness from their preferred drug lists (also known as formularies).  Further, these same guidelines also limit the ability of plans to impose restrictive policies such as prior authorization and step therapy for medications in these protected classes. 

Read NAMI's comments on the new formulary guidance

Renewal of Transition Guidance

A separate guidance to Medicare drug plans issued last week by CMS requires them to cover all medications prescribed to a new enrollee for their initial 30-day period of enrollment.  This transition guidance specifically mandates that a drug plan must immediately refill any prescription in the initial coverage period, so long as the beneficiary was prescribed the drug prior to enrollment (whether the specific medication is within the six protected classes or not).  This guidance has been in effect since January 1 of this year and continues through March 31, 2006.  For the 2007 plan year (which will begin on January 1, 2007) the transition refill requirement will again apply to any new enrollee or existing Medicare beneficiary who switches to a new plan.

Read NAMI's comments on the new transition guidance

Recent CMS Part D Drug Benefit Notices

Last week, CMS issued new notices covering a range of issues related to the new Medicare drug benefit.  These notices are designed to help frontline providers -- including physicians and Community Mental Health Centers (CMHCs) -- better navigate the new benefit.  Among these are factsheets that:

  1. Help doctors assist their patients access seamless coverage and seek exceptions to access medications not on a plan's formulary or subject to an access restriction (prior authorization & step therapy). Click here to view the physician factsheet.
  2. Help agencies that serve homeless individuals access the new benefit.  Click here to view the homeless factsheet.
  3. Provide updated guidance on immediate coverage at the beginning of the month for dual eligibles who switch plans.  Click here to view this guidance.

NAMI encourages advocates to share these factsheets with doctors, case managers, CMHC directors, and others that are helping consumers -- especially those who are dually eligible for Medicare and Medicaid -- cope with the new program.

Finally, earlier this week CMS issued a warning for beneficiaries on avoiding a recently uncovered scam that induces beneficiaries to sign up for a fraudulent drug plan.  Click here to view the anti-fraud announcement.

Please Let NAMI Know About Your Experiences With Medicare Part D

If you (or a family member) have personal experience with the new Medicare drug benefit (positive or negative) -- particularly with specific pharmacies and Medicare drug plans -- please let us know.  NAMI will protect the confidentiality of all submissions, although the name(s) of the denied medication, Medicare drug plan and pharmacy involved will be important (i.e., the name of the dual eligible beneficiary is not needed).  You can contact the NAMI National staff with your personal experiences under Medicare Part D at OR 1-888/999-6264, ext. 1228

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