Statement Of Mark B. McClellan, M.D., PH.D. Administrator, Centers For Medicare & Medicaid Services
March 16, 2005

MEDICARE FACT SHEET
FOR IMMEDIATE RELEASE CONTACT:
CMS Public Affairs
(202) 690-6145

(Editor’s Note: Today CMS issued guidance to health plans and pharmacy providers that may apply to participate in the new Medicare prescription drug plan beginning in January 2006. The guidance sets standards for plans so the transition to Medicare’s prescription drug plan can be effective, especially for people living in long term care facilities and for beneficiaries who now have other types of coverage. It should be noted that all prescription drug plans must provide services to long-term care beneficiaries. The deadline for plan applications is March 23. The guidance papers can be viewed in their entirety.)

Drug plans that want to serve Medicare beneficiaries enrolling in the new prescription drug benefit next year must meet strict standards to assure that older and disabled Americans will be able to make the transition to the new coverage smoothly.

For many beneficiaries, the new drug benefit will involve no changes, and we have previously issued guidance to ensure that plans provide access to all medically necessary treatments. But because each participating plan will have its own drug list or formulary, we will require plans to have a carefully drawn strategy for moving beneficiaries from drugs they currently take to equivalent drugs if that beneficiary’s prescription is not on a drug plan’s current formulary.

If the beneficiary’s physician believes changing a drug is not in the best interest of the patient, each plan must allow appeals and have a process to handle those appeals. The plan should also fill a patient’s current prescription for one 30-day supply to ease the transition or to keep the patient stabilized during an appeals review. If such refills are not provided, plans must have an equivalent effective transition plan in place.

Provisions must be made for beneficiaries who receive both Medicare and Medicaid and who may have been automatically enrolled in a plan where the formulary may not include all of the beneficiary’s current medications.

We are also today outlining requirements that must be met by prescription drug plans and providers serving Medicare beneficiaries who live in long term care facilities. These minimum performance and service standards include requiring a long-term care pharmacy to have a comprehensive inventory of drugs commonly used in a long-term care setting, the ability to package the medications in the unit-of-use packaging typically used in nursing homes and be able to provide a qualified pharmacist to be on-call 24-hours a day, seven days week, including holidays.

The guidance today is one part of our commitment to an effective implementation of the prescription drug coverage. We will continue to seek input from all stakeholders, with the goal of a smooth transition to this important new benefit which for the first time will help all Medicare beneficiaries pay for the drugs they need.

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