The report said that prescription drug plan sponsors use prior authorization in some circumstances for certain drug classes to ensure drug reimbursement is limited to medically accepted indications. The prescription drug plan sponsors told the inspector general that they have real-time access to the compendia, but not historical access to DrugDex.
The inspector general's office had previously recommended that the CMS use prescription drug plan sponsors' access to information about claims to ensure accurate reimbursement, a recommendation that the CMS did not support.
That report had found that more than 50% of Medicare Part D claims for atypical antipsychotic drugs used by elderly nursing home residents in the first six months of 2007 were erroneous because the claims did not match the authorized medically accepted indications.
“This memorandum report provides further evidence to support the prior recommendation,” wrote the inspector general. “We continue to encourage CMS to work with” prescription drug plan sponsors to improve the appropriateness of Part D reimbursement.
The CMS responded, saying it does not have the “statutory authority to require physicians to include diagnosis information on prescriptions, which are generally governed by state law.” The agency also said that prior authorization can be costly for the sponsor and would place a burden on the prescriber, pharmacy and beneficiary.