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CMS Issues Clarification of Formulary Oversight Process and HPMS and Formulary Finder Tool Coordination 

December 13, 2005

On November 22, CMS issued a statement to inform partners of the outcome of a quality assurance (QA) analysis of formulary data from and the health plan management system (HPMS) for six classes of clinical concern.  The analysis identified drug plan formularies that did not contain one or more drugs from these six classes of clinical concern -- including antipsychotics, antidepressants, and anticonvulsants.  Lack of inclusion of these drugs on the Formulary Finder tool was primarily due to a technical issue.

This discovery of inadequate coverage is alarming given the importance of the CMS "all or substantially all" coverage for Part D plan enrollees with severe mental illness and other chronic conditions.  This policy requires Medicare drug plans to cover "all or substantially all" medications within six therapeutic categories.  This same policy limits the ability of these plans to impose restrictive practices such as prior authorization and "fail-first" requirements with respect to medications in these classes. 

CMS contacted plans to correct any deficiencies that existed in either data source (HPMS or The errors noted on the Medicare Prescription Drug Plan Finder tool are being fixed immediately by plan sponsors.   HPMS formulary files will be updated during the open period from December 12-16, 2005, where applicable.  CMS will continue to perform additional QA reviews to ensure that approved HPMS formulary files are being displayed appropriately to beneficiaries.

Any potential discrepancies on plan Web sites or the Medicare Prescription Drug Plan Finder tool should be directed to CMS for further investigation.

Click here to read the clarification statement issued by CMS.