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Guarantee of Drugs Ends Today for Medicare Drug
Plans
Many worry some
senior citizens will not be able to get needed drugs
March 31, 2006 The extended transitional period
for the Medicare drug program a time during which the insurance plans
agreed to cover all necessary drugs for enrollees ends today and some
are predicting serious problems ahead for beneficiaries and are pressing
Medicare for another extension.
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"We are concerned there will be a serious problem
in April as beneficiaries go to the pharmacies and discover their drugs
are not covered," said Marc Steinberg, senior health policy analyst for
Families USA, a consumer group in Washington.
The end of the guaranteed coverage means that
beneficiaries, especially dual-eligibles and those with chronic
conditions, could face new roadblocks when trying to obtain drugs they
need but that their plans do not cover, according to Families USA.
Contrary to the assertions by Families USA, the
Pharmaceutical Care Management Association says "multi- tier
formularies, increased use of generics, and other proven pharmacy
management tools help improve quality and reduce costs for seniors in
the new Medicare prescription drug benefit and, in tandem with
Medicare's appeals and exceptions process, ensure seniors get the drugs
they need at an affordable cost."
Medicare officials said insurance plans have
notified patients if they are receiving drugs that will no longer be
covered after the transition period ends, according to a report in the
San Francisco Chronicle. At the same time, the plans have upgraded
telephone and customer service capacities, Medicare says.
Families USA says
The Medicare drug plan providers agreed at the
beginning of the program on Jan. 1 to provide a 30-day transition period
to cover all necessary drugs for enrollees and those assigned to their
plans. Later, Medicare asked them to extend this period through March.
Many, including members of Congress and state officials, have urged
Medicare to ask for another extension.
Families USA is especially concerned about the
"dual eligibles," whose drug coverage changed from Medicaid to Medicare
Part D, are the group of enrollees most likely to be taking drugs that
are not covered by their plans. They often have complicated medical
conditions and take multiple medications.
This problem is further complicated they point out
because most dual-eligibles were automatically assigned at random to
Part D drug plans without regard to whether the plans covered all of
their medications.
"Because they are low-income, they usually cannot
pay out of their own pockets for drugs their plans do not cover," says
the statement from Families USA." In addition, because transitional
benefits are available to all beneficiaries, anyone enrolled in a Part D
plan could find out on April 1 that some of their drugs are no longer
covered."
It is this group, too, that most concerns many
state officials. As the program began this year, many of the former
Medicaid drug clients were "lost in the system" and could no longer get
their drugs. About 40 states stepped up to provide the drugs and 17 are
reportedly still doing so.
Each Part D drug plan establishes its own list of
the drugs it covers called the "formulary" - and sets its own rules
for utilization management (policies like prior authorization
requirements that limit access to particular drugs).
When beneficiaries first join a plan, they may be
taking medications that are not on their plans formulary, meaning that
their new plan does not cover them.
Since the beginning of the year, most Part D plans
have done little to inform affected beneficiaries that their supply of
medication is only temporary, according to the consumer group.
Few plans, if any, have sent personalized notices
to members whose drugs will not be covered as of April 1.
Beneficiaries are supposed to use the transition
period to either -
1. change to a different drug,
2. ask their plan for an exception, or
3. file an appeal if their plan denies their exception.
Dual-eligible beneficiaries also have the option of
changing plans.
"In every other part of the health care system,
pharmacy management tools are recognized as essential to improving
outcomes and ensuring value-based purchasing. That's why these same
protections, coupled with extensive appeals and exceptions rules, are
afforded to seniors and the disabled in the new Medicare drug benefit,"
said PCMA President Mark Merritt.
"Regrettably, efforts to erode these proven tools
would only harm seniors and turn back the clock to an unaccountable
fee-for- service system with no regard to the real dangers associated
with misuse, overuse, or underuse of prescription drugs."
The pharmacy management tools that Medicare drug
plans rely upon are similar to the same tools used by drug plans in
Medicaid, Members of Congress' own health plan, the Veterans
Administration (VA), and private plans in the commercial marketplace,
according to PCMA.
"These tools, coupled with Medicare's extensive
appeals and exceptions rights, provide consumers with an array of
quality and access protections," the PCMA statement said.
PCMA says that under the Medicare Modernization
Act, patients have the ability to receive coverage for any medically
necessary drug, whether it is included on a plan formulary or not. If
the drug is not included on a plan formulary, the patient can appeal to
have the drug covered by their Medicare drug plan. Specifically:
● If the drug is not on a Medicare Advantage drug
plan (MA) or a Medicare drug plan's (PDP) formulary, the patient can
appeal to their plan for coverage, based on a physician's determination
of medical necessity.
● Similarly, a patient may appeal a covered
drug's formulary placement to a lower cost-sharing tier.
● If the plan determines that a drug is not
medically necessary or is in an appropriate formulary tier, the patient
can appeal to an Independent Review Entity.
● If necessary, a patient can further request a
hearing in front of an Administrative Law Judge and request a review by
the Medicare Appeals Council. Medicare requires that appeals must be
resolved within 72 hours for standard coverage determinations or within
24 hours in an emergency or life-threatening situation.
● Once the drug is determined through the appeal
to be medically necessary, the plan must provide coverage for that drug.
But Families USA says, "Right now, beneficiaries
need to look out for themselves. They should talk with their pharmacists
and their drug plans to see if any of their current prescriptions are
categorized as 'transitional' medications.
"If so, they must consult with their doctor to see
if they can either safely change medications or ask their plan for an
exception (and appeal, if necessary). Each plan sets its own rules on
exception processes, which can be quite complex."
If there are "substantial problems" after April 1,
the group says CMS should act as it did in January and extend
transitional benefits for an additional period of time.
"It could also determine that most beneficiaries
have in fact switched drugs or obtained exceptions before allowing plans
to end transitional coverage."
In addition, they want states to be ready to again
provide a safety net, especially for dual-eligibles.
Families USA concluded in their statement
"Finally, in the long term, a simpler Part D program in which Medicare
delivers a comprehensive benefit would obviate most of these problems.
Such a program would eliminate the confusion caused by the dozens of
formularies and utilization rules adopted by the many different plans.
However, such a change would require Congress to intervene, and that is
not likely to happen in the near future."
Click to San Francisco Chronicle story
PCMA is the national association representing
pharmacy benefit managers (PBMs), which administer prescription drug
plans for more than 200 million Americans with health coverage provided
through small businesses, Fortune 500 employers, health insurers, labor
unions, and Medicare. Website:
http://www.pcmanet.org/
Families USA Website:
www.familiesusa.org
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