CMS To Begin Four-Week Review of Medicare Prescription Drug Plan Formularies, Including HIV/AIDS-Related Medications

Up to 145 clinical pharmacists next month at CMS will begin a monthlong work period to review formularies for private plans offering coverage under the new Medicare prescription drug benefit, including HIV/AIDS-related medications, CQ HealthBeat reports (CQ HealthBeat, 3/14). The rules that dictate which drugs must be covered under the new prescription drug plans, released in January and based on guidelines by the United States Pharmacopeial Convention, specify 146 types of medications that Medicare should cover, including HIV/AIDS medications. USP specified that the private drug plans should offer beneficiaries at least two drugs in each category, including at least one product from each subclass within a category, and said that Medicare officials should require insurers to justify the exclusions of drug subclasses by providing "substantial clinical, scientific or other rationale." CMS also stipulated that a health plan must cover a drug if a doctor certifies that it is medically necessary for a patient, regardless of whether it is on the formulary. Medicare beneficiaries without existing prescription drug coverage will be able to enroll in the program beginning in November, with coverage beginning Jan. 1, 2006. Enrollment will remain open until May 2006, after which time beneficiaries wishing to enroll will have to pay higher fees. Under the final rules, the average beneficiary enrolling in the prescription drug plan will pay an estimated $35 in monthly premiums, as well as a $250 annual deductible. Medicare will cover 75% of the next $2,000 in prescription drug expenses. After that, beneficiaries will pay full drug expenses until their total annual expenditures reach $5,100. Medicare will cover 95% of drug costs after that point (Kaiser Daily Health Policy Report, 1/24).

HIV/AIDS Drugs Implications
Babette Edgar, head of the CMS Medicare Drug Benefit Group's operations division, on Monday at a forum on formularies sponsored by the Kaiser Family Foundation said that formulary reviewers next month plan to ensure prescription drug plans cover "substantially all, if not all," drugs in certain categories, including HIV/AIDS drugs, according to CQ HealthBeat. However, an unnamed HIV advocate at the forum told Edgar that an HIV/AIDS-related drug could be covered by the plan and not be "accessible" if the plan's cost-sharing tiers required a high copayment for the drug, CQ HealthBeat reports. Edgar said CMS is "open to review" of the cost-sharing issue, according to CQ HealthBeat (CQ HealthBeat, 3/14).

A kaisernetwork.org HealthCast of the Kaiser Family Foundation workshop on the use of drug formularies is available online.