Drug plans agree to use uniform e-messaging

June 5, 2006

A new set of standardized electronic messages, endorsed after anintense six-week effort, may alleviate some of the problems withthe Part D Medicare benefit, according to pharmacy organizations.

In the wake of the extensive glitches with the new coverage, insurers and pharmacists groups, urged on by the Centers for Medicare & Medicaid Services, hammered out a consensus for additional, uniform messaging in four areas: (1) when a particular drug is not covered; (2) when prior authorization is required; (3) when plan quantity or other coverage limitations have been exceeded; and (4) when the pharmacy is not part of the Part D plan's network.

The groups also worked out two new reject codes: "Not Covered under Part D by Law," for products that are excluded under Part D as mandated by the Medicare Modernization Act, and "This medication may be covered under Part B and therefore cannot be covered under Part D for this beneficiary."

"It's a step in the right direction," said Bruce Roberts, R.Ph., CEO of the National Community Pharmacists Association, at the press conference. He called the creation of the new messages "a solid measure that will make it a little easier for pharmacists to help patients cut through the red tape."

Robert Hannan, interim CEO of the National Association of Chain Drug Stores, said the messages will give pharmacists information that's often been missing, a factor that stopped or slowed prescription filling.

Ignagni said health plans had learned it is not enough for the messages to be similar from plan to plan. "This is a story about uniformity. If you are on the ground as a pharmacist, turning on that computer screen, if we can deliver as a community, as stake holders working together, uniformity, consistency, and certainty," that will make the program work better, she said.

CMS administrator Mark McClellan, M.D., Ph.D., said, "I want to be clear that Medicare now views these consistent messages as best practices for the drug benefit. We expect the entire industry to adopt and implement these practices as soon as possible. CMS will be looking at these and other best practices as measurements of plan performance in the weeks ahead."

Lawrence Kocot, senior adviser to the CMS administrator, who works on pharmacy issues, told Drug Topics the agency is ready to begin asking plans if they are conforming to these messaging formats and it is ready to hear from R.Ph.s if plans don't use them. He said some plans have already been sending these messages.

Both the pharmacy groups and the insurance association admitted they were impressed with the "unprecedented" collaboration they put forth to agree on the messages. The cooperation, Roberts said, "is just beginning and has potential to have profound positive impact on the healthcare delivery system, far beyond, actually, Part D."

McClellan said the action, by preventing phone calls and delays, "may add up to a significant reduction in costs in time and effort for pharmacists across the country to fill prescriptions.... This is how you make health care work better and faster and cheaper and easier."

Calling pharmacists leaders in the movement toward the electronic health records, McClellan also said the collaborative effort was "a great precedent that will likely lead to further standards in messaging." He added that "pharmacies of this country have demonstrated how important they are in the implementation of the Medicare drug benefit. They have been tremendous."

The listing of the standardized messages also showed that, under "Plan limitations exceeded," there are five possible messages:

Information on the new messages is on the AHIP Web site at http://www.AHIP.org/.

THE AUTHOR is a writer based in Maryland.