EyeNet Magazine


 
Opinion
Too Soon to Refill? The Bean Counters Don’t Always Win
By Richard P. Mills, MD, MPH, Chief Medical Editor, Eyenet
 
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“I ran out of drops because the bottle was only half full when I bought it.” “Do you have a sample to tide me over until my insurance will refill my eyedrops?” “Sometimes I’m not sure if I got a drop in, so I use another, and then I run out before the end of the month.” Sound familiar? They are all recurring refrains in my glaucoma practice. Three years ago at the American Glaucoma Society (AGS) meeting, Alan Robin, MD, of Baltimore, showed a sobering, candid video of patients actually using their eyedrops, even after they had been instructed in proper technique.1 Suddenly it became clear why so many patients need early refills, which are denied by their insurers. Insurers and their pharmacy benefit managers (PBMs) put limits on refill frequency to avoid overutilization (and perhaps to curb shadowy street corner dealing of eyedrops), assuming that 1 drop = 1 dose, but Dr. Robin’s video showed that to be an invalid assumption.

Cindie Mattox, MD, of Boston, and Sam Solish, MD, of Maine, became interested in brokering a solution but discovered, like with most things political, logic wasn’t enough to convince anyone to change things. A statement on eyedrop refills drafted by Dr. Mattox and ratified by the AGS later became a joint information statement of the AGS and the Academy. Not enough; the PBMs claimed there were too few patient complaints to warrant a change. Time to roll out the heavy artillery. Dr. Solish, who serves as an Academy AMA delegate, found Sandy Marks, MBA, assistant director of federal affairs for the AMA, who has a mother with glaucoma. She and her mother had experienced the refill problem firsthand, and she formally forwarded ophthalmology’s concerns to the Medicare officials overseeing Part D. And Koryn Rubin of the Academy’s D.C. office began contacting the PBMs with additional information. Still not sufficient, since Medicare had not received enough beneficiary complaints. So Dr. Mattox and Ms. Rubin got information out to AGS members on how patients could complain to Medicare. I remember handing out quite a few of those complaint forms to my patients. Complaints began pouring in. Meetings with glaucoma patient support groups and the ophthalmic industry gained additional allies in the battle. Finally in June 2010, CMS issued guidance on early refill edits (computer software that denies early refill requests) so that patients may obtain eyedrop refills at 70 percent of the predicted days of use. This means that a month’s supply can be renewed at 21 days. In addition, refill allowances apply to both retail pharmacies and mail-order sources. Finally, physicians can request even earlier refills for beneficiaries who continue to have difficulty with inadvertent wastage.

The battle is not over, since major insurers and their PBMs are not required to follow Medicare’s guidelines. But at least an ophthalmologist inclined to advocate for a patient whose eyedrop aim is inaccurate has available some ammunition: an Information Statement from the AGS and the Academy, and Medicare Part D edit guidelines.2 Half full or half empty? At any rate, Medicare patients will be able to refill their drops earlier than they used to.
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1 Stone, J. L. et al. Arch Ophthalmol 2009; 127:732–736.
2 www.aao.org/one, choose “Practice Guidelines,” “Clinical Statements,” then “Glaucoma.”

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