Each day thousands of “Baby Boomers” sign up for the various Medicare programs. In simple terms, “Part A” deals with hospital “room and board” and hospice care; “Part B” deals with inpatient and outpatient tests and procedures, medical devices and certain types of medication;” “Part C” refers to “HMO” type plans, which include Parts A, B, and D. Medicare “Part D” deals with qualifying medications, which are not covered by Medicare “B”.
Pharmacy benefit managers, (PBM’s) or pharmacy sponsors are very aware of the complicated, intricate rules and regulations of Medicare “D”.
At MRIoA, we are always working to improve our expertise involving Medicare programs and other PBM products. Commercial insurance programs have their own unique variations, which are partly determined by the state laws in which they do business. Each Commercial plan may have its own definition of “Medical Necessity”, “Experimental/ Investigational” as well as what level of evidence is required in order to provide a medication.
For Medicare “D” the details of the relevant portions of policies and procedures are contained in chapters 6, 15, and 18 of CMS law and apply to all Medicare “D” medications.
The compendia required for support as well as the level of support are precisely delineated for cancer cases. Specific rules for making Prior-Authorizations Exceptions or Formulary Exceptions are also defined.
While this summary may create the idea that the adjudication of Medicare “D” cases is straightforward, it is actually quite difficult.
MRIoA is dedicating a lot of resources to keeping our team of Medical Directors skilled in adjudicating Medicare cases. Our team of Medical Directors is all board certified in various medical specialties including Emergency Medicine, Family Practice, Internal Medicine, Physical and Rehabilitation Medicine, Neurology, Pathology, and Otolaryngology.
We are ready for the tremendous growth the “Baby Boomers” will bring to all parts of Medicare, particularly Medicare “D”.
Bennion D. Buchanan, MD, FACEP, MBA