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Choose Carefully as Medicare Drug Benefit Deadline
Nears on May 15
Kaiser Family Foundation
finds wide variations
across plans
April 14, 2006 - Medicare’s new private stand-alone drug plans vary
significantly – in terms of covered drugs, out-of-pocket costs for
specific medications, and restrictions placed on the use of certain
drugs - according to a new analysis released today by the Kaiser Family
Foundation.
(Editor's Note: This foundation has done extensive
research and analysis on the Medicare Drug Program. See a list of links
to their information below news story.)
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Related Stories |
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Final Medicare Enrollment Effort Begins Monday
Across the U.S.
Hundreds of events
planned for 'Medicare Rx Get Enrolled Week'
April 12, 2006 – With the deadline for enrollment
for the Medicare drug program looming – May 15 – and new polls showing
satisfaction with the program, a week-long grassroots effort is being
held April 17-23 in all 50 states and Washington D.C. to help senior
citizens get enrolled. Medicare Today, a national partnership of more
than 400 organizations, today announced "Medicare Rx Get Enrolled Week."
Medicare experts and volunteers will provide seniors with the
information they need to make decisions about enrollment in Medicare's
prescription drug benefit.
Read more...
Read more
on
Medicare Drug Program |
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“The drug law was designed to encourage competition
among plans, and in that respect, it's working. But because there are
big differences from plan to plan, choice matters,” Kaiser Family
Foundation President Drew E. Altman said.
“What’s not yet clear is how
well people with Medicare can sort through all these differences to make
informed decisions.”
The study examined formularies, drug costs and
utilization management tools in drug plans offered by 14 national and
near-national organizations.
These organizations offer 35 unique
prescription drug plans that account for a total of 1,222 of the 1,429
packages available to Medicare beneficiaries. The study examined a
sample of 152 generic and brand-name drugs, selected to include both
drugs commonly used by Medicare beneficiaries, such as those treating
high cholesterol and high blood pressure, as well as some less common,
high-cost drugs used to treat specific conditions such as osteoporosis
and rheumatoid arthritis.
The study was conducted by Jack Hoadley of
Georgetown University, Elizabeth Hargrave of the National Opinion
Research Center at the University of Chicago, and Juliette Cubanski and
Tricia Neuman of the Kaiser Family Foundation.
Key findings include:
● On average, the plans cover 81 percent of the
drugs in the sample, ranging from 64 percent in the most restrictive
formulary to 97 percent in the least restrictive formulary. None of the
studied drug plans cover all 152 of the sample drugs.
● Formulary comprehensiveness varies considerably
by drug group. Averaged across all plans in the study, about 90 percent
of antidepressants, beta blockers, and tumor necrosis factor inhibitors
(used to treat rheumatoid arthritis) are covered on plan
formularies,compared to about 60 percent of hormonal agents (mostly used
to treat osteoporosis) and proton pump inhibitors (used to treat
gastrointestinal problems).
● The cost-sharing that enrollees pay for a given
drug when it is covered on the plan’s formulary varies considerably
across Medicare drug plans. For example, an enrollee could pay from $15
to $62 for Norvasc (for high blood pressure), $15 to $66 for Fosamax
(for osteoporosis) and $15 to $100 for Namenda (for Alzheimer’s
disease). The most dramatic variation across plans is for Enbrel (for
rheumatoid arthritis),with cost sharing that varies from a low of $20 in
one Medicare drug plan to $1,276 in another plan that covers the drug
but charges enrollees 75 percent of its total cost.
● The most common cost-sharing arrangement is a
three-tier system of copayments. Among the 21 plans with such
arrangements, the median cost sharing is $5 for first-tier drugs
(generics), $25 for second-tier drugs (preferred brands) and $53 for
third-tier drugs (non-preferred brands).
● Many plans use a “specialty tier,” primarily
for biotechnology or injectable drugs. Although CMS issued guidelines
encouraging plans to charge beneficiaries no more than 25 percent of the
cost of these drugs, eight of the 21 plans using a specialty tier charge
between 30 percent and 33 percent. For the specialty tier drugs in the
study’s sample, beneficiaries must pay between $149 and $450 for a
one-month supply in plans that cover these drugs. Beneficiaries may not
be able to request an exception to have specialty tier drugs covered on
a lower cost-sharing tier, as they can for other covered drugs,
according to CMS rules.
● Plans vary significantly in the frequency that
they restrict enrollees’ access to specific drugs through quantity
limits, prior-authorization requirements, and step-therapy provisions
(that require enrollees to try a less costly drug before receiving a
more expensive alternative). Four of the studied plans use these tools
on fewer than one in 10 of their covered drugs, while 13 plans do so on
at least one in four covered drugs.
“With so much variation, it’s critical that the
government monitor the plans’ formularies and restrictions carefully to
ensure people with Medicare get a fair deal no matter what plan they
choose,” said Georgetown University researcher Jack Hoadley, Ph.D., one
of the authors of the study.
For the full study in Adobe pdf format –
click here.
Click to more news on the
Medicare Drug Program.
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Additional Resources on the Medicare
Prescription Drug Benefit
The Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 was signed
into law on December 8, 2003. The Kaiser Family Foundation
has compiled some resources to reflect the latest
information, as well as background materials on various
parts of the law.
Key Resources:
Medicare Drug Law -- Overviews, Summaries, and General
Information
Issues related to the Drug Benefit
Low-Income Beneficiaries and the Medicare Drug Benefit
Discount Card Program
Medicare Advantage (MA) and Private Drug Plans (PDPs)
Public Opinion on the New Law
Dual Eligibles and Issues Related to Their Transition to the
New Medicare Drug Benefit
Background Resources:
Discount Cards
Employer/Retiree Coverage
Additional Data/Resources
Key Resources:
Medicare Drug Law --
Overviews, Summaries, and General Information
●
Medicare Prescription Drug Enrollment Update
●
Medicare Prescription Drug Plan Information, by State, 2006
●
Medicare Prescription Drug Benefit Fact Sheet (updated
September 2005)
●
Key Implementation Dates for the Medicare Prescription Drug
Benefit (updated June 2005)
●
Summary of Final Regulations Implementing the New Medicare
Prescription Drug Benefit
●
Summaries of the Medicare Prescription Drug Improvement &
Modernization Act of 2003
●
Medicare Benefit Chart
●
Medicare Q&A Weekly Column
●
KaiserEDU Issue Module: New Medicare Prescription Drug
Benefit
●
KaiserEDU Tutorial: Medicare Prescription Drug Benefit
●
Medicare Drug Benefit Calculator
●
Statehealthfacts.org: Medicare Beneficiaries with Creditable
Prescription Drug Coverage by Type, as of February 11, 2006
●
Statehealthfacts.org: Distribution of Medicare Beneficiaries
with Creditable Prescription Drug Coverage by Type, as of
February 11, 2006
Issues related to the Drug
Benefit
●
Tracking Prescription Drug Coverage Under Medicare: Five
Ways to Look at the New Enrollment Numbers
●
Prescription Drug Spending Under the MMA: Modeling the
Impact on Out-of-Pocket Costs
●
The Impact of Enrollment in the Medicare Prescription Drug
Benefit on Premiums
●
The Effects of Formularies and Other Cost Management Tools
on Access to Medications: An Analysis of the MMA and the
Final Rule
●
A Comparison of Proposed and Final Regulations Governing
Medicare Part D Plan Enrollment and Part D Benefit Appeal
and Grievance Procedures
●
Marketing and Privacy Issues: An Analysis of the MMA and
Proposed Regulations
●
The New Medicare Drug Benefit: Potential Effects of Pharmacy
Management Tools on Access to Medications
●
Issues for Medicare Beneficiaries in Long-Term Care
Facilities: An Analysis of the MMA and Proposed Regulation
●
Consumer Protection Issues Raised by the Medicare
Prescription Drug, Improvement and Modernization Act of 2003
Low-Income Beneficiaries and
the Medicare Drug
Benefit
●
Fact Sheet on Low-Income Assistance Under the Medicare Drug
Benefit (updated September 2005)
●
Low-Income Subsidies for the Medicare Prescription Drug
Benefit: The Impact of the Asset Test
●
The New Medicare Prescription Drug Law: Issues for Enrolling
Dual Eligibles into Drug Plans
●
Implications of the New Medicare Law for Dual Eligibles: 10
Key Questions and Answers
●
Implications of the New Medicare Prescription Drug Benefit
for State Medicaid Budgets
●
Issues for Medicaid and Low-Income Beneficiaries in the
Medicare Drug Debate
●
Impact on Institutionalized Medicare Beneficiaries
●
Issues for Dual Eligibles with Disabilities and Serious
Conditions
●
The "Clawback:" State Financing of Medicare Drug Coverage
●
Additional Help with Rx Drug Costs for Low-income People on
Medicare
●
Discount Card Program
●
Medicare Drug Discount Cards: A Work In Progress
●
The Medicare Prescription Drug Discount Card Program:
Implications for Low-Income Medicare Beneficiaries
Medicare Advantage (MA) and
Private Drug Plans (PDPs)
●
Medicare Health Plan Tracker
●
Medicare Advantage Fact Sheet (updated September 2005)
●
Profile and Analysis of the 26 Medicare Advantage Regions
●
Potential Effects of Pharmacy Management Tools on Access to
Medications
● Public Opinion on the
New Law
●
The Medicare Drug Benefit: Beneficiary Perspectives Just
Before Implementation (November 2005)
Selected Findings on
Knowledge and Understanding of the New Medicare Rx Drug
Program from the Kaiser Health Poll Report:
●
February 2006;
December 2005;
July/August 2005; March/April
2005;
May/June 2004;
March/April 2004; Jan/Feb
2004
●
Views of the New Medicare Drug Law: A Survey of People on
Medicare
●
Views of the New Medicare Drug Law - Chartpack on People
with Disabilities
●
Views of the New Medicare Drug Law - Chartpack By Income
Group
●
Medicare Focus Groups: What Are Seniors Saying?
●
National Survey on the Public's View on Medicare and
Prescription Drugs (September 2003)
Background Resources:
Discount Cards
●
Savings for Medicare Beneficaries from the Use of
Prescription Drug Discount Cards
●
Designing a Medicare Drug Discount Card: Implications of
Policy Choices for Medicare
●
Prescription Drug Discount Cards: Programs and Issues
● Prescription Drugs
●
Prescription Drug Coverage and Seniors: Findings from a 2003
National Survey
●
Employer/Retiree Coverage
●
Prospects for Retiree Health Benefits as Medicare Drug
Coverage Begins: Findings from the Kaiser/Hewitt 2005 Survey
on Retiree Health Benefits
Additional Data/Resources
●
Handout of Kaiser Family Foundation Key Web-Based Medicare
Resources (.pdf)
●
Talking About Medicare and Health Coverage: Your Guide to
Understanding the Program
●
Medicare Chartbook (updated July 2005)
●
Medicare at a Glance Fact Sheet (updated September 2005)
●
Medicare Spending and Financing Fact Sheet (April 2005)
●
KaiserEDU Tutorial: Medicare 101
●
State-level Poverty Data for the Medicare Population
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Information provided by the
Medicare Policy Project
Publish Date: 2005-07-21 |
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