A rule meant to provide greater flexibility to who can prescribe drugs under Medicare Part D may open up a window of abuse for the program.
In May, the CMS issued an interim rule that allowed Medicare Part D plans to continue to reimburse pharmacy claims for prescriptions written by “other authorized prescribers.” The change was necessary as a growing number of states have designated pharmacists as providers with broadened scopes of practice, which may include prescriptive authorities.
However, pharmacists and other authorized prescribers must enroll in Medicare. Prior to enrollment, the CMS allows plans to reimburse for a three-month provisional supply of drugs when the prescription is written by a prescriber who is eligible to enroll but failed to do so.
The plan must also provide individualized written notice to the beneficiary that the supply is being provided on a provisional basis. The policy is meant to give these prescribers the chance to enroll in the program, while not hindering access to medications, however it's this same provision that plans and other stakeholders say opens the program to additional abuse.
For instance, oxycodone is available from multiple manufacturers and there are an estimated 23 National Drug Codes (NDCs) for the painkiller. An NDC identifies the company that manufactures or distributes the drug.
“Were a beneficiary to receive a provisional fill for one NDC, once that fill is exhausted their prescriber could have as many as 22 additional NDCs to choose from before all three-month provisional fills would finally be exhausted,” Sergio Santiviago, director of Government Affairs at Express Scripts, said in a comment to the CMS.
The pharmacy benefit manager recommends that the CMS identify drugs by ingredient rather than NDC to prevent abuse.
Health plans are also concerned the permission could cause problems. “As we understand it, there is no finite date on when claims would begin to reject, but rather it is an open-ended approach that could last up to a year,” Jane Galvin, managing director of Regulatory Affairs at the The Blue Cross Blue Shield Association, said in a comment.
The CMS has already been put on alert about current drug abuse taking place under Part D. HHS' Office of Inspector General released two reports last month on the issue. A subsequent House Energy and Commerce Subcommittee on Oversight and Investigations hearing addressed the issue.
It's unclear how the CMS may end up altering the three-month policy. A spokesman would say only that the agency takes prescription drug abuse seriously. He added that in 2013, the CMS began providing quarterly reports with potential opioid or acetaminophen overutilization issues identified through analyses of prescription drug event data.
“Sponsors are required to respond to the CMS within 30 days on the status of the review for each beneficiary case,” the spokesman said.