On Tuesday, July 23, the Senate Finance Committee released draft drug pricing legislation, the Prescription Drug Pricing Reduction Act (PDPRA) of 2019. This sweeping bill would make a number of changes aimed at addressing the high and rising costs of prescription drug prices.
However, the legislation currently does not contain important changes to the Medicare Part D appeals process. With mark-up of the legislation happening today, Thursday, July 25, the Center for Medicare Advocacy joins our friends at Medicare Rights Center in urging inclusion of the bipartisan Streamlining Part D Appeals Act (S. 1861), introduced by Senators John Cornyn (R-TX) and Ben Cardin (D-MD) into the Senate Finance Committee’s drug pricing bill.
Currently when a Medicare beneficiary is refused a prescription at the pharmacy counter, they may not know the reason and next steps necessary to obtain their medication. To find a resolution, beneficiaries often have to correspond with both their Part D plan and their prescriber on multiple occasions, which may involve many phone calls and long wait times, often up to several days. For many older adults and people with disabilities, this is dangerously too long to go without needed medication.
The Streamlining Part D Appeals Act (S. 1861) would simplify this process by allowing a denial at the pharmacy counter to serve as a coverage determination. Allowing a refusal at the pharmacy counter to function as the plan’s initial coverage determination creates the provision of a detailed, formal denial notice at the point-of-sale. This denial would give people with Medicare more timely access to actionable information about their plan’s coverage decision, and eliminate unnecessary steps within the current system – including the need for beneficiaries to request pre-coverage determination information and counsel from their plans and providers. Beneficiaries would be empowered to more easily exercise their appeal rights and obtain an independent review.