Beginning January 1, 2006, nursing home residents, including all those dually eligible for Medicare and Medicaid (the dual-eligibles) and many Medicare-only residents will enroll in the Medicare drug benefit (also known as Part D). The benefit will be administered by private health plans, managed care organizations, and pharmacy benefit managers (PBMs) acting as prescription drug plan sponsors. There will be enrollees in different drug plans within the same nursing home.

The Medicare drug benefit guarantees enrollees access to any medically-necessary drug. However, the drug plans are expected to use preferred drug lists and other pharmacy benefit management tools, such as step therapy, prior authorizations and tiered copayments, to manage drug costs. The plan formularies have been reviewed by the Centers for Medicare and Medicaid Services (CMS) to ensure that they provide adequate access to medications in all therapeutic categories. The formularies must be developed, reviewed, and maintained by pharmacy and therapy committees, which must include some independent and geriatric specialists. CMS is requiring that formularies include all drugs in six drug classes (antidepressants, antipsychotics, antiretrovirals, anticonvulsants, antineoplastics, and immunosuppressants) as well as the most commonly prescribed drugs in the Medicare population.

The law does exclude several classes of drugs from coverage under the Medicare Part D benefit, including over-the-counter medications, benzodiazepines, barbiturates, and weight loss/gain agents. It is possible that state Medicaid programs may continue to cover these drug classes for the dual-eligibles; we do not know at this time whether states will cover these drugs and if so, to what extent.

CMS has instructed plans to develop a policy that lays out the rules for transitioning people from their current drug regimen to plan-covered drugs; each effected nursing home and long-term care pharmacy should be made aware of the plan’s policy. Your patients may still have access to non-formulary drugs, but you may need to get prior authorization or go through the plan’s exceptions process for coverage. Plans must develop both a regular and expedited (for emergency requests) formulary exceptions process.

KPS Pharmacy is working to transition patients to this new benefit as smoothly as possible, so that your patients have the best quality pharmacy service available. We will update this site as more information is released by CMS and the plans serving our patients.

Q: Will the process for getting a prescription dispensed change in the nursing home?

The process of getting a prescription dispensed will not materially change; your KPS Pharmacy pharmacists will continue to provide you with the same high-quality services.

Q: What if one of my patients is on a non-covered drug?

If your patient is on a drug that is not covered under their plan’s formulary, you may still prescribe that drug. The nursing home staff or pharmacist will facilitate the exceptions process for your patient or identify other benefit options.

Q: How will I know what drugs are covered for which patients?

KPS Pharmacy will manage all of the formulary issues in your nursing home and will help you determine the appropriate formulary drug.