Audio CD and written materials of AIS's audioconference on October 26, 2006

Part D Coverage for Specialty Pharmacy Drugs: Resolving Complex Problems That Remain

Year one of the Medicare Part D program is nearly over, but confusion still reigns among health plans, pharmacy benefit managers, pharmacies, providers, and beneficiaries regarding which outpatient drugs are covered under Part D and which are covered under Part B. Nowhere is this more apparent than in the area of specialty pharmacy drugs, including those for oncology, transplant patients, and home infusion. When this confusion is combined with the cost of these drugs and beneficiary problems accessing them, there are very complex issues to resolve that have great implications for patient outcomes, revenue streams and compliance.

Sponsored by Atlantic Information Services, Inc., publisher of A Guide to the Medicare Drug Benefit, Medicare Part D Compliance News, Specialty Pharmacy News and Drug Benefit News

Speakers Designed For Shipping Information Written Materials Print an order form: If you do not wish to place your order online, click here to download a printable order form (PDF file), then submit your order via fax or mail, as directed on the form.

Order Now (Secure Site) CD and Printed Materials ($292) Pub code: CMDSPT View Cart

There are many complex issues regarding the provision of specialty pharmacy drugs to beneficiaries under Part D, including the lack of clarity as to whether some specialty pharmacy drugs should be categorized as Part D or Part B. These "gray area" drugs — i.e., oral anti-cancer drugs, immunosuppressives, home infusion drugs — can potentially be covered under Part D or Part B, depending on the particular circumstances. Thus, PBMs and pharmacists are confused about where to bill these drugs. Often, neither pharmacists nor plan sponsors know if a drug is billed correctly, which leads to revenue and compliance issues.

In addition, not all specialty pharmacy drugs and equipment are covered under all plan formularies. For example, while the Part D benefit does cover infused drugs and the ingredient costs and dispensing fees associated with such drugs, it does not cover some equipment, supplies, and professional services associated with home infusion therapy. And although a recent study determined that nearly all generic cancer drugs and 70% of brand-name cancer drugs are covered by Part D plans, approximately 10% of cancer treatments were found to be subject to restrictions such as prior authorization. Moreover, these drugs are usually very expensive, causing beneficiaries to reach the Part D coverage gap, or "donut hole" — between $2,250 and $5,100 in total drug expenses for 2006 — sooner than other beneficiaries.

Listen in as two Medicare and specialty pharmacy experts discuss how to determine the correct coverage for these specialty pharmacy drugs. You will hear the specifics on which circumstances trigger coverage under Part D vs. Part B for these most problematic drug types, and how plans and pharmacies can work together to make sure these drugs are categorized correctly. You also will learn what plans can and should do with regard to covering these drugs on their formularies, including which tiers they should be placed on, and permissible ways of setting restrictions on beneficiary access.

Our experts will help you navigate the complexities of:

Speakers

JENNIFER BOWMAN is a director of Avalere Health LLC, where she leads strategic client engagements on behalf of FORTUNE 500 pharmaceutical and biotechnology clients and patient advocacy groups focused on the implementation of the Medicare prescription drug benefit. Her projects involve analyzing legislation, regulations and guidance documents, and helping clients determine the impact of those changes on their business strategies. Prior to joining Avalere Health, Ms. Bowman was a health analyst from 1999 to 2002 with the Congressional Budget Office (CBO), where she focused on developing estimates of the cost impact of legislation on health plans. She is a contributing author on a number of CBO publications, including cost estimates, studies, and congressional testimony. She earned an M.P.H. in health policy from Yale University and a B.A. in biochemistry from Rice University.

MARY JO CARDEN, RPh, JD is president of Carden & Associates, a health care policy and advocacy firm that provides guidance, research, advice, strategic planning, and advocacy on health policy and legal issues, including Medicare Part D and Part B and other public and private pharmacy reimbursement programs and medication therapy management programs. Prior to forming Carden & Associates, Ms. Carden served as a principal of Dumbarton Group & Associates, LLC. She has also worked for the American Society of Consultant Pharmacists. Ms. Carden holds a bachelor of science in pharmacy from the University of Pittsburgh School of Pharmacy and a Juris Doctor degree from Catholic University of America in Washington, DC.

Moderator: Barbra Golub, JD, managing editor of AIS's A Guide to the Medicare Drug Benefit and Medicare Part D Compliance News

 

Designed Especially For

 

Shipping Information

Audio CDs and written materials are shipped via UPS. Please give us your street address when you order (UPS does not deliver to PO boxes). You should receive your order within 5-7 business days.* Shipping cost is $5.

Rush Orders: Please call us at 800-521-4323 to place a rush order.* We will overnight your order for an additional charge of $30, or you can give us your FedEx or UPS account number and we will charge the shipping to your account. Rush orders placed after 3:00pm EST will not be shipped out until the next business day.

Written Materials