CMS Vows to Police Medicare Prescription Benefit Formularies

Drug plans providing prescriptionbenefits to seniors under the newMedicare drug program will comeunder tight scrutiny from federal officialsto ensure that they provide a fairbalance between cost containment andthe needs of elderly patients, MedicareChief Mark McClellan told Congress.

Testifying before the Senate SpecialCommittee on Aging, McClellan saidthat his Centers for Medicare and MedicaidServices (CMS) will issue "clearbenchmarks" for health plans to use toensure that the formularies they designfor the new program are not discriminatoryand provide seniors with"access to medically necessary prescriptiondrugs."

McClellan said the agency will alsopressure plans to ensure that their formularies"recognize the special needsof particular types of beneficiaries,such as mental health patients, thosewith HIV/AIDS, those living in nursinghomes, people with disabilities, andother beneficiaries who are stabilizedon certain drug regimens."

The law creating the new Medicaredrug benefit requires that formulariesused in the program include at least 2drugs in each approved category andclass, but McClellan told Congress thathis agency will view that requirementas the bare minimum.

"CMS may require formularies toinclude more than 2 drugs per categoryor class in cases in which additionaldrugs offer unique and important therapeuticadvantages and where theirexclusion may substantially discouragebeneficiaries with certain diseases fromselecting the plan," he said.

Mr. Rankin is a freelance medical writer.