The initial enrollment period for Part D ended on May 15, 2006, and the Senate Finance Committee observed the first anniversary of that date with oversight hearings on the program. Sen. Max Baucus (D, Mont.), committee chair, asked for advice on legislative or administrative actions that would yield "honest and responsible improvements." Recommendations from patient advocates and pharmacists drew a good share of attention.
Advocates named formulary policies among the most perplexing aspects of a complicated program that needs better outreach, a simplified choice process, and curbs on abusive marketing. Pharmacists cited unfair-or nonexistent-negotiation with plans, low reimbursement rates, payment delays, and delayed price updates as their sore points. Senators from both political parties expressed gratitude to pharmacists for helping to launch the complex program and pledged their support for fair and timely compensation in return.
Compensation for pharmacists was viewed as too low and too slow by the committee members. Tobey Schule, R.Ph., of Kalispell, Mont., questioned the rationale supporting a Medicare dispensing fee of $1.25 while the plan pays $6.00 for the same service under an employersponsored plan. He pointed to the increase in profitability of the drug plans compared with declining profits and closings of small, independent pharmacies as illogical.
GAO responded to an inquiry from Sen. Charles Grassley (R, Iowa), ranking minority member of the committee, about the difficulties faced by Medicare beneficiaries who subsequently qualify for Medicaid. Grassley learned about the problem from a pharmacist in his home state. Although beneficiaries are covered from the date they first meet Medicare requirements, PDPs have not always paid retrospectively for prescriptions dispensed before plan information was available to the pharmacy. An estimated 634,000 beneficiaries became dually eligible during 2006. GAO recommended that PDPs notify beneficiaries promptly of their right to retroactive payments and that CMS monitor payment policies better.
Information that Senators obtained from R.Ph.s in their home states and at the hearing caused them to question whether it is fair to allow PDPs to change formularies midyear without giving beneficiaries the opportunity to change plans as well. Beneficiaries disabled by mental illness and their need for stable drug therapy regimens were a particular concern.
Coverage determination and exception requests are vague and complicated processes, said patient advocates. …