CMS in collaboration with our partners has been working to simplify administrative processes and create common procedures throughout the Medicare Part D program. To that end, America’s Health Insurance Plans (AHIP), the National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA) met with CMS Administrator Mark B. McClellan, MD, PhD, to announce standardized coding messaging designed to assist pharmacists and better serve beneficiaries when they fill prescriptions at pharmacies.
Specifically, these standardized electronic messages will help pharmacists quickly determine the appropriate course of action for filling beneficiaries’ prescriptions under four different circumstances: (1) when a particular drug is not covered; (2) when prior authorization is required; (3) when plan quantity or other coverage limitations have been exceeded; and (4) when the pharmacy is not part of the Part D plan’s network. These organizations' agreement on this messaging will result in the consistent use of key terms by Part D plans and thus allow pharmacists to more quickly address issues at the pharmacy counter.
In addition, Dr. McClellan announced the formation of the Pharmacy Quality Alliance (PQA). PQA will aim to improve pharmacy care and outcomes through a collaboration of the pharmacy community, health plans, government, employers, physicians, and consumers. The goal of PQA will be to agree on a strategy for measuring and reporting data that will help consumers make informed choices and appropriate healthcare decisions.
"Pharmacists and pharmacies have demonstrated how important they are to the implementation of the Medicare drug benefit, and we’re pleased to support these collaborative efforts,” said Dr. McClellan. “The PQA is an important next step in supporting pharmacists’ efforts to improve quality and reduce costs in our health care system,” he said.
To further the goal of simplifying procedures in the new drug benefit, last week the American Medical Association (AMA) and America's Health Insurance Plans (AHIP), in conjunction with CMS, released a standardized exceptions form designed to assist physicians in applying for exceptions and prior authorizations on behalf of Medicare beneficiaries enrolled in Medicare drug plans. This form allows for a simplified process for physicians to apply for coverage determinations on behalf of all of their Medicare patients, regardless of which Part D plan the beneficiary is enrolled in.
The letter and accompanying attachment on standardized coding the and standardized coverage determination form are available online by using the links below.
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