Medicare Rx formularies to get R.Ph. Review

April 18, 2005

Uncle Sam has given up to 145 clinical pharmacists the job of reviewing the formularies of drug plan sponsors seeking to be part of the Medicare prescription drug benefit that is set to begin on New Year's Day, 2006.

Uncle Sam has given up to 145 clinical pharmacists the job of reviewing the formularies of drug plan sponsors seeking to be part of the Medicare prescription drug benefit that is set to begin on New Year's Day, 2006.

Twenty clinical pharmacists who work for the Centers for Medicare & Medicaid Services will be joined by up to 125 on-call pharmacists employed by a contractor, according to Babette Edgar, Pharm.D., director of finance and operations for the Medicare Drug Benefit Group in CMS. She said the staff and contract pharmacists would have about one month to review the proposed formularies, which were due April 18. The agency has set aside two weeks for the review and another two weeks to negotiate any changes with plan sponsors and pharmacy benefit managers. The agency will then notify plan sponsors about whether it will accept or reject the proposed formularies by May 18.

While CMS has enlisted pharmacists, it's also relying on its computer system to deal with 75% to 80% of the formulary-checking workload, said Edgar at a policy workshop conducted in the nation's capital by the Kaiser Family Foundation. "What it will do is kick out where there are problems within the formulary, and at that point, there will be a clinical pharmacist who will review those particular outliers," she added.

"It is a very resource intensive process that we're going through to ensure that this particular review is both nondiscriminatory and provides appropriate access," said Edgar. "The [plan sponsors] have dealt with the over-65 population in the commercial benefit. So there is experience in terms of what drugs work for the elderly and what drugs do not work. We are anticipating that the formularies that come through will have perhaps some issues, but we expect the reviews to go very smoothly at this point."

CMS had outlined its formulary requirements for Rx plans in January. For example, plans must include two drugs in each therapeutic category and pharmacological class in USP's model guidelines or an acceptable alternative. In addition, Edgar said CMS would require formularies to include all or a majority of drugs in six categories-antidepressants, antipsychotics, anticonvulsants, antineoplastics, immunosuppressants, and HIV/AIDS.