Long Term Care: Medicare Prescription Drug Coverage in Institutions and Our Communities

1. Long Term Care: Medicare Prescription Drug Coverage in Institutions and Our Communities Larry Kocot Vanessa Duran

2. MMA Requirements regarding Access to Part D Drugs in LTC Facilities • Section 1860D-4(b)(1)(C)(iv) of the Act requires convenient access to Part D drugs for residents of LTC facilities. • Sec. 107 of the MMA requires a report to Congress: • Assessing the current standards of practice, clinical services, and other service requirements generally used for pharmacy services in long-term care settings • Evaluating the impact of those standards with respect to patient safety, reduction of medication errors and quality of care.

3. Regulatory Access Standards for LTC Pharmacies (§423.120(a)(5)) • Plans must demonstrate convenient access to LTC pharmacies • Offer standard contracting terms & conditions to all I/T/U pharmacies in service area • Must contract with “any willing pharmacy” • Standard terms and conditions must conform with certain performance and service criteria for the provision of LTC pharmacy services established by CMS in further guidance • CMS has provided separate guidance regarding how convenient access to LTC pharmacies will be assessed

4. Regulatory Network Access Standards for LTC Pharmacies (§423.120(a)(5)) • Anticipated benefits of our LTC access policy: • Plans may negotiate more competitive market rates with LTC pharmacies • LTC facilities will likely be able to select just one LTC pharmacy to serve their residents • May allow LTC facilities to negotiate more competitive rates for additional services for their residents from LTC pharmacies

5. LTC Guidance: LTC Pharmacy Performance and Service Criteria • Comprehensive inventory and inventory capacity • Pharmacy operations and prescription orders • Special packaging • IV medications • Compounding/alternative forms of drug compositions • Pharmacist on-call service • Delivery service • Emergency boxes • Emergency logbooks • Miscellaneous reports, forms, and prescription ordering supplies

6. LTC Guidance: Convenient Access • Convenient access to LTC pharmacies for 2006: • Work plan • Performance and service criteria • Contracting with any willing pharmacy • Attestation of convenient access and list of network LTC pharmacies by August 1, 2005 • Convenient access in future contract years may look at: • Enrollment/disenrollment rates • Complaints • Linking beneficiaries to LTC pharmacies to verify LTC pharmacy capacity

7. LTC Guidance: Formulary • Plans must have a single formulary for all enrollees • Plans must establish an appropriate transition process for new enrollees: • Procedures for medical review of non-formulary drugs • Procedures for switching enrollees to therapeutically equivalent alternatives failing affirmative medical necessity determination • Temporary one-time supply fills recommended • Documentation of range and circumstances impacting transition timeframes • Other transition methods (e.g., contacting enrollees in advance of initial effective date of enrollment)

8. LTC Guidance: Exceptions & Appeals • We expect plans to consider interrelationship between LTC facility, LTC pharmacy, attending physician, and relevant laws and regulations in establishing grievance, coverage determination, and appeals processes • Part D sponsors must clearly articulate financial responsibility of plans when Part D requirements and Medicare conditions of participation (COPs) conflict • Recommend that plans consider one-time temporary or emergency supply process as a stopgap while an exception or appeal request is in process • Regulations allow an appointed representative to act on an individual’s behalf