Medicare Part-D Payment Issues

[pharmdmba]

For 2009, are any health plans or pharmacies experiencing incorrect payments for Part-D medications from Medicare or Medicaid?

Are the drug payments for your organization or pharmacy "fair"?

What new approaches (besides MTM) would you recommend that would enhance patient medication safety?

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[diana.papshev]

Anonymous feedback:

"I was concerned as well regarding the new CMS HRM reporting that began last fall. Since there is a bit of a quandry at times with CMS regulations (e.g. medications within the 6 protected classes yet also identified as a HRM). My PBM is working on developing a new Retro DUR program to investigate the issue of utilizing a ACE/ARB with Type II DM in addition to our existing Potentially inappropriate Medication Retro DUR which we have run twice in the past 3 years and will probably repeat again in 2010. Our PBM has also identified a number of HRMs (e.g. propoxyphene) that we were able to remove from our 2010 formulary although I am afraid that it changed our generic coverage designation thru the coverage gap from ALL generics to MANY generics - lastly, I have served on an advisory committee for our state's QIO to develop our own HRM or PIMs list which will be distributed throughout the state to providers, pharmacist, LTC's, etc to try and repeat the message to those groups as well. Lastly, I have developed provider newsletter articles that do double duty as educational inserts with my retro DUR mailings."

[diana.papshev]

Anonymous feedback:

"This is to reply to question #2 - enhance patient medication safety.
We use soft edits (POS DUR messages) for medications that require monitoring, but use hard edits (ie Prior auths) for medications that require extensive monitoring."