Medicare Part D Plans Must Ensure Prescription Drug Access in Disaster Areas
This week the governors from Kentucky, Ohio, and Indiana all declared a state of emergency in response to Friday’s barrage of deadly tornadoes and widespread storm damage. By requesting the declaration, these states can expedite the process of getting Federal Emergency Management Agency (FEMA) assessment and assistance teams into communities that need it most. It also means that all Medicare beneficiaries who live in these communities will be able to get immediate refills of any prescription drugs lost in the storms.
When disaster strikes, there’s no such thing as “refill too soon”
According to guidelines from the Centers for Medicare & Medicaid Services (CMS), all Medicare Part D prescription drug plans must guarantee immediate refills of Part D medications for any members located in an area that has been declared a major disaster. In addition, because of certain conditions that might exist during an emergency, such as a reduced number of operational pharmacies, limitations on transportation and travel, and the disruption of U.S. mail service, plans must also allow an affected beneficiary to get the maximum extended day supply of the drug, if requested and available at the time of refill.
In other words, any time a disaster has been declared, Part D plan sponsors must remove what is called the “refill too soon” (RTS) edit for affected members, for the period of the emergency declaration.
What the “refill too soon” edit means to you
Even if your community has never been declared a disaster area, it’s important for you to know about the RTS edit and how it can affect your access to your prescription drugs. Most people outside of the insurance or pharmacy benefit industry don’t know about this edit, but I think it is very worth sharing this inside information with you.
If you’ve ever tried to refill a prescription for a long-term drug a few weeks early, your claim was probably rejected at the pharmacy. Your pharmacist would have told you to come back in a week or so, because your Medicare Part D plan wouldn’t pay for a refill yet. This is the RTS edit in action.
When your pharmacist receives the “refill too soon” message from your Part D plan, it means you are trying to refill a prescription before a certain percentage of your current medication has been used. For example, let’s say your Part D plan requires that at least 75 percent of your medication from the previous order be used before you can get a refill. If you order a 30-day supply (30 pills) of a certain medication every month, you must wait at least 23 days—in other words, you must have already taken 23 pills or 75 percent of your medication—before you can order another refill.
The rationale behind the RTS edit is that it is an effective way for prescription drug plans to minimize excessive use, waste, and stockpiling of medication. I do agree that the RTS edit is a good rule to help prevent people from hoarding bottles of pills or using more drugs than their doctor has prescribed. But I’m also glad that CMS had the good sense to recognize that when disaster strikes, some rules must be broken.