Explanation of Medicare D PDP spreadsheet Utilization Management Terminology

These spreadsheets only cover the 2-tier zero-net-premium plans to which dual eligible patients were auto-enrolled. Feel free to modify these as your needs dictate, just change the attribution line at the bottom of the page. The terms QL, PA and STEP will be familiar to afficiandos of the Medicare Formula Finder and commercially managed drug formularies, but not perhaps to everyone. I was drawn to constructing these spreadsheets (with a great deal of design help and encouragement from Drs. Stevan Gressitt and Ed Pontius of the Maine Association of Psychiatric Physicians) because since most psychiatric medications are in the “protected classes” for 2006 and 2007 they generally cannot be excluded from a Medicare D formulary, as can drugs in other classes. Patients who have Medicaid and Medicare, so called “dual eligibles” and other highly subsidized beneficiaries are required to pay relatively small copays of between 1 and 5 dollars per prescription (more than most duals paid before, as Medicaid usually did not require the copay to get the medications, while Medicare D forbids pharmacies from advertising a policy of not requiring the copay). But otherwise, cost to the consumer is not a very effective way of managing demand for patients in these highly subsidized plans, as it has been in commercial insurance up to now.

So the utilization management or UM tools that the plans are required to publish, and for medications not in the protected class, formulary placement per se, constitute the major difference between the plan offerings for dual eligibles. It is my understanding that after the rebidding process for plan year 2007 that people currently in plans that will not be offering a zero-net-premium 2 tier plan for duals next year will be re-auto-enrolled to whatever plans are standing for 2007, so it will be useful to update these sheets quickly at that time to reflect these changes (and the upcoming formulary changes that are expected in August) so that people can be aware of their choices before the new plan year starts. We will be posting updated information for the national plans as new information becomes available (see below).

Because Medicare D is still under construction, the operational meaning of these utilization management tools or “edits” as they are sometimes called is not always clear, and clarifying this is something that needs to happen as soon as possible. Here is my best shot:

PA: Prior Authorization. The medication will only be granted if there is a special request for it, justifying its use for a particular patient. What sort of information will satisfy the plan will probably vary from plan to plan. In my opinion, the patient’s clinical presentation and past experience with medications, as determined to indicate medical necessity by the treating clinician, should trump any demand for a priori statistical evidence that the medication is likely to work.

QL: Quantity Limits. This edit is hard to interpret without knowing the details. Some plan formularies list these explicitly on their formularies or websites, some do not. Limiting the amount of smaller size pills is reasonable, as these are more expensive than larger size pills, and often a daily dose of psychotropic medication can be consolidated in one dose. But limiting the amount of the largest size pills limits the total daily dose, and not all people respond to the doses in the middle of the dose response range where the published research tends to be done. Often it is the most expensive medications that are limited in total dose, while cheap generics may be limited regarding the number of smaller pills, but not the larger. Quantity limits seem to be involved in the controversial practice of challenging doses that patients were on at the start of Medicare D for “safety” reasons when in fact the patient had been tolerating the dose fine and there was no particular evidence that a higher than usual dose was unsafe. This practice was challenged by advocacy organizations, it is not clear at this writing what the outcome was. But because QL is tangibly defineable in a number, it should be simple to get the number and post it for the public to see. Try calling the plan in question and ask them about this.

STEP: This generally means you have to try medications in sequence if you want to get them without the equivalent of a PA. I take the posting of the STEP edit without the PA edit to mean that if you can find out what the sequence desired is and it gets into the billing that the company computer can see, then you will get the medication without further remonstration: this is sometimes called EST in the plan formularies. Not to be confused with the old abbreviation for what is now called electroconvulsive therapy, EST means electronic step therapy, or the computer will figure it out automatically. This is a nice idea, however at this point it seems unlikely with all the other transition confusion that the plans have much idea of what the patient was prescribed prior to January 1, 2006; the absence of this data continuity has caused a lot of trouble and contributed to the transition period being extended by CMS. STEP therapy is used by many commercial pharmacy benefit managers, and some Medicaid PDL’s. It has the advantage of being potentially explicit in what you have to do to get a medication, and also could be construed as supporting the increasingly popular concept of using treatment algorithms like the TMAP for schizophrenia and bipolar disorder.

And for my spreadsheets:

Y: Stands for yes, you can get it. No UM edits posted. Not clear if this precludes “safety” edits but it should.

N: Stand for no, it is not on the formulary. You can ask for an exception and appeal if denied. Some plan formularies list medications they do not intend to pay for as tier 5 describing them as “non-formulary”, some, I have been told, have even higher tiers. It is not clear to me how all this translates to two-tier formularies for duals. Formula Finder lists some meds that the published plan formularies do not, but which seem likely to be covered; sometimes I have had to guess about this.

For atypical antipsychotic use, step therapy is controversial; preliminary data from research such as the CATIE study is being hotly debated, and the various atypical antipsychotics are generally more different from each other and from cheaper generics than are the more expensive and therefore highly managed antidepressants and mood stabilizers from their generic alternatives. They are also much more expensive than most other medications, so cost control will focus on these medications eventually. It is not clear to me what the rules of using the STEP notation on the plan formularies is; I was told by one plan that CMS requires that all medications in a step sequence be noted as STEP, when in fact most of them are freely available without trying anything first; it is usually only the last medications in the series that actually are subject to UM. STEPS are rare in the formularies now, probably for some of the reasons discussed above, and seem to be the UM edit most commonly involved in discrepancies between the Medicare Formula Finder and the plan formularies on their websites. If you see a cheap generic medication like trazodone or fluoxetine with a STEP edit on it, this would generally seem to mean that these are medications that you are supposed to try before trying something expensive, but not that their use is restricted by UM. In my opinion if this in fact a convention that CMS is asking for, it should be changed so that only medications that require another medication to be tried first are listed as STEP.

So why do we need these sheets if we have Epocrates?

Most of the dual eligible were “auto-enrolled” to one of the plans in their region whose premium for that region was below the cutoff; there were considerable problems in the enrollment process, but the bottom line is that dual eligibles are allowed to change plans monthly. Thus to the extent that Medicare D is said to involve market competition between the various private companies that have entered a winning price bid to serve disabled and low income people (in general the plans for duals also serve the low income “special help” Medicare beneficiaries who do not have Medicaid), getting accurate and accessible information to the beneficiaries is essential so that they can see what the plan differences are. While most regions have very large numbers of seemingly different plans seeking to cater to different parts of the Medicare market, for the dual eligibles, the numbers of plans range from 6 to 15 in any one region for plan year 2006, a limited enough range that each region can list these plan offerings on one page.

What about everybody else?

For people who are purchasing the “standard” Medicare D products, without the additional subsidies that dual eligible and special help people get, price and other issues like donut hole coverage and deductible can all be tweaked to produce a dizzying array of products, that are much harder to compare than the two-tier, highly subsidized formularies that we highlight here for psychiatric medications. It will be interesting to see if information products can be designed to clarify these choices; one would expect this to happen, as the buyers of the standard plan represent an enormous market with a good deal of discretionary income. This is not the market we are addressing here, so we need to be clear that these spreadsheets are for the duals and special help recipients. That is why we have not attempted to include pricing tiers on these sheets.

Inspired by an early effort by the New York Office of Mental Health, which in December 2005 posted a spreadsheet for a large number of commonly used medications that were likely to be managed from general medical care, the Maine Association of Psychiatric Physicians has posted spreadsheets covering GI, pain, sleep, cardiovascular, diabetic and other nonpsychiatric medications at www.mainepsych.org, and update the information about once a month. Hopefully, the attached spreadsheets for psychiatric drugs can be similarly expanded so that providers and consumers can see the overall best plan for any patient. A memo from CMS dated April 27 2006 indicates that plans must get CMS approval for any UM edit changes during the plan year, that such changes must have a good reason, and that beneficiaries must be informed of these changes. Furthermore, people taking a medication will not be retroactively subject to new UM edits. Hopefully this will mean that these sheets will not have to be updated as frequently as I originally thought. I will be updating a master sheet of the national plan formularies that make up most of the plans for duals in each region, so the updates can just be cut and pasted into a regional plan as long as the sequence of medications has not been changed. We will probably not be updating regional plans, so our regional champions are asked to check the data for the regional plans that only do a plan for duals in one or two states. We will post this master sheet on this website when it is time for an update, or contact me at benjamin.crocker@att.net.

I have been greatly encouraged in this project by the American Psychiatric Association, the Maine Association of Psychiatric Physicians and the American Association of Community Psychiatrists, but all the of the content and any erroneous information contained is entirely my responsibility. I would appreciate feedback about stuff I have wrong or other suggestions to improve these sheets. Most of all I am hoping that some people will adopt them, post them, maintain them with updates and use them as a start for customized local sheets.

Benjamin Crocker, MD

PO Box 4040

Portland. Maine 04101

207-771-2004 ex 235

benjamin.crocker2@att.net