Some Medicare Part D Beneficiaries Face Avoidable Extra Steps That Can Delay or Prevent Access to Prescribed Drugs

WHY WE DID THIS STUDY

This evaluation examines data and oversight related to Part D pharmacy rejections and coverage denials that, when issued for avoidable or inappropriate reasons, can lead to delays in beneficiary access to needed drugs. Part D is an optional benefit that helps beneficiaries pay for medically necessary prescription drugs. However, Part D's shared-risk payment model can create an incentive for sponsors to deny requests for prescription drugs in an attempt to increase profits. Because Part D covers more than 45 million beneficiaries, even low rates of denied or delayed medically necessary drugs or reimbursement could contribute to physical or financial harm for Medicare beneficiaries.

HOW WE DID THIS STUDY

For each Part D contract, we collected 2017 data on pharmacy rejections related to formulary and utilization management requirements and on coverage denials, appeals, and appeal outcomes. We calculated applicable volumes and rates. We also analyzed data from the independent entities that review the higher levels of Part D appeals. To examine CMS audit findings, we analyzed the 2017 results for the Part D program audits and the related enforcement actions, and 2017 data from the formulary administration analysis. We also examined CMS websites to determine the location of information about sponsor performance.

WHAT WE FOUND

Ideally, a Medicare beneficiary would be prescribed only medically necessary drugs, and would obtain any required preapprovals or exceptions before visiting a pharmacy so that prescriptions could be filled without extra steps. However, in 2017, Part D insurance companies ("sponsors") rejected millions of prescriptions presented at pharmacies, and overturned a large number of drug-coverage denials when beneficiaries appealed. This pattern indicates that the ideal scenario does not always occur.

In 2017, sponsors' automated systems rejected millions of prescriptions that beneficiaries tried to fill at pharmacies. Some of these rejections could have been avoided if the prescribed drugs were on the approved drug lists, met requirements, or received any required preapprovals. Although sponsors should reject prescriptions that do not meet requirements, the affected beneficiaries may still have needed medications and may have filed coverage requests, paid out of pocket, or contacted their providers to request different drugs. These extra steps can delay beneficiaries' access to needed drugs, or deter them from getting them if they are unable or unwilling to navigate the process.

After receiving rejections at pharmacies, beneficiaries can file coverage requests, and if those are denied, they can appeal. Among coverage denials that beneficiaries appealed in 2017, sponsors fully overturned or partially overturned 73 percent. These overturned denials could have been avoided if sponsors had received, and correctly processed, all relevant information at the first request.

Through its oversight efforts, CMS has determined that sponsors sometimes inappropriately rejected or denied pharmacy and drug coverage requests. These errors led to inappropriate denials or delays of beneficiary access to prescribed drugs.

WHAT WE RECOMMEND

We recommend that CMS (1) take additional steps to improve electronic communication between Part D sponsors and prescribers to reduce avoidable pharmacy rejections and coverage denials; (2) take action to reduce inappropriate pharmacy rejections; (3) take action to reduce inappropriate coverage denials; and (4) provide beneficiaries with clear, easily accessible information about sponsor performance problems, including those related to inappropriate pharmacy rejections and coverage denials. CMS concurred with all four recommendations.