Earlier this year, the Centers for Medicare & Medicaid Services (CMS) issued rules for Medicare Part D prescription drug plans that required dialysis patients to get prior authorization for their medications. This resulted in delays as some dialysis patients had to wait for authorization before accessing medications to fight infections, nausea, pain, and anxiety among other ailments. This past Friday, after many conversations between CMS leadership, National Kidney Foundation staff, professional volunteers, and other organizations representing kidney professionals and patients, CMS reversed its guidance and is now encouraging Part D plans to change their policies so that patients no longer have delays getting certain medications.
Medicare payment for dialysis is bundled into one lump sum per treatment, designed to cover both the costs of providing the dialysis treatment and certain medications used to treat dialysis related side-effects that can be given orally or intravenously (IV). As a result, there were disputes about who should pay for medications when it wasn’t clear if the medication was prescribed for an issue related to dialysis treatment. For example, antibiotics could be used to treat a dialysis catheter related infection (dialysis related) or they can be prescribed to treat an infected foot-wound (not dialysis related). Since it wasn’t always clear to the pharmacist or to the Part D plan whether the drug prescribed was used to treat something dialysis related, Part D plans required the prescribing health care practitioner to submit documentation as to why the drug was being prescribed. It could take anywhere from a few hours to a few days for a healthcare practitioner to receive the request for documentation, complete it and get it back to the pharmacist. This meant patients had to wait to get their medications, leaving many confused and worried about their health.
NKF advocated for patients to receive their medications immediately and not be turned away from the pharmacy counter because of confusion over who should pay for the medications. We are pleased with CMS’s new guidance and are hopeful that patients no longer receive a delay in accessing their medications.
If you are a dialysis patient and are either denied your medications or asked to pay for the entire cost of your medications, contact your healthcare provider right away. They may be able to help by contacting the pharmacy, dialysis facility or insurance company on your behalf, or by prescribing an alternative medication that your insurance will pay for. Any delay in taking your medications could make you sicker or put your life at risk. If you still are unable to get your medications after speaking with your healthcare provider, contact our NKF Cares helpline at 1.855.NKF.CARES (1.855.653.2273).