But the AMA vehemently objects, saying the policy would empower health plans to overrule doctors' medical decisions, thus preventing patients from getting drugs for pain and other conditions they legitimately need.
The policy "will engender significant confusion when beneficiaries pick up prescriptions and (are) informed that their insurance plans have denied coverage," AMA executive vice president James L. Madara, MD wrote in a March 2 letter to Medicare Director Jonathan Blum.
"It has the potential to be highly disruptive to patient-physician relationships and undermine their mutual trust. Serious medical consequences would exist if Part D plans suddenly disallow legitimate prescriptions and create conditions leading to the under treatment of pain," Madara wrote.
But the CMS document says that Part D drug plan sponsors "are in a unique position to evaluate medication overutilization" because they are "a central data collection point for beneficiary medication dispensing events, which may be generated from multiple providers and pharmacies, which may be unaware that a beneficiary is receiving the same drug (or therapeutic equivalent) simultaneously from different providers and pharmacies."
"To the contrary," Madara wrote, "Part D sponsors are not in a position to evaluate medication overutilization. The only information they have is the various claims that are submitted for prescription coverage. Sponsors do not know diagnoses and they do not know about any other services the patient is receiving that do not involve Part D coverage."