CMS Directs Drug Plans to Expedite Coverage Decisions
[Posted 02/02/06 ]

To ensure that Medicare patients have uninterrupted access to medically necessary prescription drugs, the Centers for Medicare & Medicaid Services (CMS) has directed all Part D prescription drug plans to expedite coverage decisions for Medicare beneficiaries. The plans must make and communicate coverage decisions within 24 hours for an “expedited” request and 72 hours for a standard request.

Physicians can request an expedited decision if the patient’s health will be seriously jeopardized by waiting 72 hours for a standard decision.

CMS also directed all plans during this transition period to provide patients on stabilized drug regimens with at least a 30-day supply of their current medications, even if their particular drug is not on their plan’s formulary. The Bush administration has also asked drug plans to provide beneficiaries with an additional 60-day supply in emergency cases.

If these back-up systems fail, physicians and patients should immediately call 800/MEDICARE to resolve the issue and get patients their medications.

Click here for more details, including drug plan contacts and information on appealing a coverage decision.