• Community Care Rx^SM News
• Medicare News
• Ask the Experts

Are your cash patients Part D holdouts? Are they concerned that they will be unable to afford the Part D premiums because they live on limited incomes? Becoming ill and requiring expensive medications will be more taxing on a patient’s limited monthly income than the Part D premium. If you know your patients are not signing up for Part D because of cost, encourage them to apply for the low income subsidy (LIS) through the Social Security Administration. More information about the LIS and an online form are available on www.ssa.gov. It doesn’t cost anything to apply, and your patients may find they qualify for significant financial assistance with monthly premiums and copays.

It’s not too late to request an enroller from Community Care Outreach Services (CCOS) for your store. With the new online enroller request form on CCRx.net, your request is handled expeditiously. Upon logging in to CCRx.net, you will see a prompt at the top of the page to request an enroller. Click on the link, complete the short form, and submit. CCOS enrollers to date have been a major source for total CCRx enrollments. Leave the enrollment process in the hands of a consultative, trained, and licensed agent, so that you and your staff can take care of patients and keep business flowing.

Patients who enroll now through April 30 will be effective with CCRx on May 1. Enrollments received by CCRx May 1-15 will be effective on June 1. No change has been made that extends the initial Part D enrollment period beyond May 15 or that the premium penalty of 1 percent per month will be waived. Eligible patients need to enroll today!
 

In January CCRx implemented a temporary process for ID and transition requests that included special forms and a dedicated fax number. With the significant improvement in call center response times, CCRx has discontinued the use of the forms and fax number. When requesting a member ID number or initial transition request, pharmacists can receive an immediate response by calling the Pharmacy Tech Center (PTC) at 866-684-5395.

All valid forms remain available on CCRx.net. Pharmacists and physicians are encouraged to utilize the provider Web site, CCRx.net, to access any necessary forms. All forms are located under the link “Provider/Physicians,” which does not require password access. The forms posted on the Web site are recently revised. Please discard any old forms you may be using. Available forms include:

• Prior Authorizations
• Step Therapy Exception
• Nonformulary Drug Request
• Quantity Limit Exception
• Tiering Exception

Providers must expeditiously complete these forms in their entirety and fax them to the number indicated on the form, so that the process is seamless to the patient. Additionally, the CCRx formulary is accessible from the same page containing the forms.
 

There are two types of Medicare beneficiaries who are receiving letters about facilitated enrollment: full subsidy and partial subsidy. If a full subsidy beneficiary wants to switch plans, the following applies:

• Beneficiaries receiving Supplemental Social Security Income (SSI) or applied and qualified for extra help: can switch plans at least once until the end of the calendar year. After the calendar year, they can switch once between Nov. 15 and Dec. 31 each year.
• Beneficiaries receiving help from Medicaid (belong to a Medicare Savings Program): can switch plans anytime.

Beneficiaries that are on a partial subsidy and receiving facilitated enrollment letters can switch to a different Medicare Part D plan at least once until the end of the calendar year, and once each year after, between Nov. 15 and Dec. 31.

To switch plans the beneficiary needs to enroll in the new plan. They will be automatically disenrolled from the old plan, and the new plan’s benefit will begin on the first of the next month following enrollment.
 

The 2006 CCRx/MemberHealth pharmacy claims payment schedule is now posted on the NCPA and Medicare Resource Center Web sites under the CCRx section. Pharmacists may now review payment cycles and the corresponding payment date.

To improve cash flow and as a thank you to pharmacists for their hard work, payments for dates that fall on weekends will be released on the Friday before the weekend. If you participate in the CCRx Electronic Funds Transfer (EFT) program, that money will likely be deposited in your account on the payment date.

Still not on EFT? It’s not too late to participate. EFT registration forms are available on the CCRx Updates page on the Medicare Resource Center Web site. You can also call the Pharmacy Tech Center (PTC) at 866-684-5395 for more information.
 

CCRx mailed Coordination of Benefits (surveys) to patients in accordance with CMS Medicare Part D guidelines. The COB survey is used to determine whether the patient has other drug coverage. Please encourage your patients to complete the survey in a timely manner and return it to CCRx in the envelope provided.
 

Provigil is subject to CCRx prior authorization requirements because of its side effect profile in the elderly and potential for inappropriate, off-label use.  Provigil will only be approved for FDA-approved indications or as a last-line option for patients with documented treatment-resistant depression. Off-label use for other indications is not justified at this time due to lack of clinical evidence or because of the existence of other treatment options.

Elderly patients are more susceptible to the CNS and sympathomimetic adverse effects of CNS stimulants.  Elderly patients with diminished renal and hepatic function often require dosage reduction to prevent accumulation of modafinil and its metabolites. The CNS stimulants have a high potential to result in dependence and complicate the management of hypertension, angina, ischemic heart disease, and myocardial infarction.

Excessive sleepiness is a symptom with a broad differential diagnosis, such as sleep apnea, side effects of sedating medication such as opioids, restless leg syndrome (RLS), sleep disruption due to medical causes, symptom of diseases such as multiple sclerosis or Parkinson’s Disease, pain, depression, or inadequate sleep as a result of voluntarily reducing sleep amounts on a repeated basis. Specific therapies have been developed for sleep disturbances due to other idiopathic causes. For example, patients with RLS may benefit from dopamine agonists (cabergoline, pergolide). Sleep apnea patients may benefit from nasal CPAP, intraoral devices, and improved sleep hygiene.  Adjusting Parkinson’s Disease medication and withdrawal of daytime sedatives may benefit Parkinson Disease patients. 

Multiple sclerosis patients may benefit from amantadine or antidepressant therapy. Opioid dose reduction and opioid rotation (the replacement of one opioid with another) may be used to manage opioid induced sedation (OIS) in patients who do not develop tolerance.  Currently, methylphenidate is the most extensively studied agent for managing OIS and is considered the drug of choice for managing this condition.  Dextroamphetamine may be considered a second-line agent.

The recommended dose of Provigil is 200 mg daily (quantity limit 30 tablets per 30 days). There is no consistent evidence suggesting that higher doses confer any additional benefit but have resulted in increased nausea and nervousness.

To assess coverage eligibility for Provigil, the Provigil prior authorization form assesses:

1. Diagnosis requiring treatment with Provigil

• Narcolepsy
• Obstructive sleep apnea/hypopnea syndrome in patient's using CPAP/BIPAP (as adjunctive therapy if necessary)
• Shift work sleep disorder
• Treatment resistant depression

The prior authorization form for Provigil is available on CCRx.net. Click on the link for Providers/Physicians. No login or password is necessary.
 

Medicare is offering the following guidance to beneficiaries that were taking a drug not covered by their Part D plan and who did not switch to an alternate, formulary medication by March 31, 2006.

• Patients should call their plans to make sure they understand the plan’s transition policy. All plans must cover an alternative drug and need to inform the beneficiary what that drug is.
• The plan must have a timely exceptions policy in place in the event the patient’s physician will not allow the therapeutic interchange.
• If the beneficiary’s Part D plan will not honor the exceptions request, the beneficiary may escalate through Medicare for an independent review.

If a patient presents at his/her pharmacy and has not switched to a formulary alternative drug, the pharmacist will receive a rejection. Medicare is instructing patients to do the following if that happens.

• Ask the pharmacist if a generic alternative is available.
• Ask the pharmacist why the drug is not covered.
• Call their doctor to see if they can take an alternate drug.
• If the doctor doesn’t think an alternate drug is acceptable, the patient should contact the plan to inquire about an exception. If the request is urgent, the plan is required by CMS to conduct an expedited review. In the meantime, the patient should inquire whether the plan will allow a temporary fill of the medication until they make a determination on the exception request.
• If the patient pays cash for a drug the plan doesn’t cover and then subsequently is granted an exception, the plan must reimburse the patient up to the amount it would normally pay if it covered the drug.
• Patients with any further questions or concerns should call 800-MEDICARE.

Because your patient’s birthday is in July, she may enroll in CCRx now through June 30 and have a CCRx benefit effective date of July 1. She will not incur any late enrollment penalty. She can enroll as late as October 31 without incurring the penalty, however, her effective date will not go retroactive to July 1.  Instead, her Part D effective date will be the first of the month following the date of enrollment. In the case of an October enrollment, her CCRx benefit would begin on November 1. Keep in mind your patient would have to start over with deductible on January 1. Enrolling in time for a July 1 effective date would help her maximize the cost savings of the CCRx benefit design.