CMS Vows to Police Medicare Prescription Benefit Formularies

MAY 01, 2005
Ken Rankin

Drug plans providing prescription benefits to seniors under the new Medicare drug program will come under tight scrutiny from federal officials to ensure that they provide a fair balance between cost containment and the needs of elderly patients, Medicare Chief Mark McClellan told Congress.

Testifying before the Senate Special Committee on Aging, McClellan said that his Centers for Medicare and Medicaid Services (CMS) will issue "clear benchmarks" for health plans to use to ensure that the formularies they design for the new program are not discriminatory and provide seniors with "access to medically necessary prescription drugs."

McClellan said the agency will also pressure plans to ensure that their formularies "recognize the special needs of particular types of beneficiaries, such as mental health patients, those with HIV/AIDS, those living in nursing homes, people with disabilities, and other beneficiaries who are stabilized on certain drug regimens."

The law creating the new Medicare drug benefit requires that formularies used in the program include at least 2 drugs in each approved category and class, but McClellan told Congress that his agency will view that requirement as the bare minimum.

"CMS may require formularies to include more than 2 drugs per category or class in cases in which additional drugs offer unique and important therapeutic advantages and where their exclusion may substantially discourage beneficiaries with certain diseases from selecting the plan," he said.

Mr. Rankin is a freelance medical writer.