I’m signed up for Medicare Part D, though it wasn’t by my choice. The company they chose for me sent me a huge packet filled with information, rules, disclaimers, and a partial drug formulary — that is, a partial list of the prescription drugs they’ve decided to cover at this time. Since local Republican politicians are swaggering in their campaign ads about how they helped create this giant headache, I thought I’d look at some details of which drugs my assigned company covers.
I freely admit I don’t have any professional training that informs me about prescription drugs. My observations are purely as a layperson looking at the formulary that people must refer to in order to see if what company and plan they will choose.
My particular company is in the Medicare Part D business in all 50 states and Washington, D.C., though co-pays and monthly premiums of plans vary from state to state. Here in Minnesota, the three different plans offered vary by co-pay, premium, and when the doughnut hole begins (though it’s federally-mandated that the doughnut hole end at $3,600). These three plans are named “Signature,” “Complete” and “Premier,” which, of course, tells you nothing whatsoever about how they actually compare. You can’t even determine basic versus fancy coverage from the plan names.
Drugs are categorized according to whether the plan covers them: “generic,” “preferred,” “non-preferred,” “specialty,” and not covered. Looking at the online Signature plan formulary, which has the lowest monthly premium, here’s what I can observe:
Under antidepressants, the only two brand-name drugs that are preferred are the MAO inhibitors Nardil and Parnate, both of which I’ve never heard of and were omitted from the formulary I received by mail. Every listed brand-name reuptake inhibitor (Cymbalta, Effexor, Lexapro, Paxil, and Zoloft) is non-preferred, meaning the consumer cost will be higher. They are all also listed as “SE,” which inexplicably stands for “step therapy.” This means that these drugs will not be covered by the plan unless you first try some other drug of the company’s choosing, probably a generic drug. There are many generic antidepressants covered, but if you don’t have a prescription for them or the brand-name equivalent, you need to visit the doctor for a new one or pay the non-preferred brand-name price.
Almost all vaccines listed are generic or preferred. A few are “specialty” and require prior authorization (PA) from the company in order to be covered.
All anti-HIV agents seem to be brand-name and preferred.
Under “bipolar agents” only Depakote and the generic lithium carbonate are in the formulary at all. Depakote is non-preferred here and wherever it’s listed elsewhere.
All but one “blood glucose regulator” is either generic or preferred. So diabetics get better coverage than those who are bipolar, it seems.
Under “dyslipidemics” — apparently cholesterol-lowering drugs — it’s a very mixed bag: There are generics. Crestor, Lescol, Vytorin and Zycor are all preferred, while Advicor, Lipitor and Zetia are not.
Cialis, Levitra and Viagra are all preferred, though quantity limits (QL) exist.
“Sex hormone modifiers” — birth control — are mostly generic or preferred. Plan B is non-preferred. Don’t tell me that’s not political.
The only “sedative/hypnotics” listed are Ambien and the generic chloral hydrate. Ambien is both non-preferred and has a QL.
All of this can be changed at any time, though consumers can only switch plans at certain times during the year. I haven’t been able to find any information on when those times you can switch plans occur.
A new Kaiser Family Foundation study resulted in the following information about Medicare Part D:
Eight in 10 pharmacists (81%) say that they have had customers who had problems getting their prescriptions. One in five (19%) say such problems affected “most” of their customers in Medicare drug plans.
Two in three pharmacists (67%) say they had customers leave the pharmacy without a medication because the prescribed drug was not on their Medicare drug plan’s formulary.
Almost six in 10 pharmacists (58%) say they had customers pay out-of-pocket for their drugs because they could not verify their enrollment in a Medicare drug plan.
Nearly half of pharmacists (49%) say they had customers leave without a prescription because they could not afford the co-pay charged under the Medicare drug plan.
Nearly half of pharmacists (45%) who serve “dually eligible” beneficiaries, who were previously getting coverage through state Medicaid programs, say that these customers experienced more problems filling their prescriptions than other Medicare customers.
Among doctors with patients in Medicare drug plans, 59% say that they have had patients who experienced problems getting their prescriptions, with 15% saying “most” of their patients in Medicare drug plans had such problems. One in 10 (10%) say that they had a patient who suffered a “serious medical consequence” as a result of such problems.
And on the business side:
More than one in four (27%) say that they had to take out a loan or a line of credit because of cash-flow problems related to the Medicare drug benefit. About three in four independent pharmacists say both that they have dispensed prescriptions to their customers without knowing whether they would be paid and that the reimbursements they receive from Medicare drug plans are less than what they get from commercial payers.
It’s hard to make conclusions from the formulary, though the Kaiser survey supports the idea that the program has a knack for denying some consumers the drugs they need. At the very least, it’s become much more troublesome to maintain your health if you have to use Part D. Choice really isn’t part of the plan. It’s been replaced by uncertainty.
Crossposted at The Gimp Parade
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That is simply effing ridiculous. Not the concept of allowed vs. costly drugs (setting limits is theoretically OK) but there’s really no reason to make it confusing. And the CATEGORIES. Sheesh. I’ve a medical background–was even a pharmacy tech once–and I wouldn’t have known “dyslipidemics” either. How the hell do they expect an average-intelligence, moderately-educated, elderly person to have a rat’s chance in a cat kennel of figuring this out? Nuts. And good luck.
Yes. Oddly, they claim the categories are “medical conditions.” But who would think to look under dyslipidemics?
Another thing that bothers me is how very much the availability of information (such as it is) requires access to the internet. You could call someone and ask a question, but you’ll spend a long time on hold and might get the wrong answer anyway.
Just to clarify, whatever else is wrong with Part D, the plan is not permitted to change the formulary at any time.
Let me give you the decoder ring for your plan:
“generic” is a drug that is a “me too” version of a brand name drug that is determined to be bioequivalent. If you have doubts about this, it is probably because your doctor is having lunch too often with pharmaceutical reps.
“preferred” equals brand name drugs in the lowest copay tier. Most health plans will not place any brand name drug in this tier if there is a generic equivalent to the brand. So if there are a lot of generic SSRIs, then, by definition, there will not be a lot of branded SSRIs that are preferred. However there are also brand name drugs that don’t have generic equivalents that are left off if there are a lot of brands overall.
“non-preferred” equals brand name drugs that are in a higher copay level.
“specialty” equals drugs that are usually administered via injection or under very specific diagnosis — like oral chemotherapy.
“not covered” equals drugs that are not covered by Part D and that the plan is not allowed to provide.
On the other hand, here is what always comes back to for health care, even though very few people like to hear it: Nobody trusts any party to be an intelligent and disinterested decision maker, but there are meaningful distinctions to be made among what are essentially very similar, competing drgus.
When it comes to drugs, health plans have more information and more ability to weigh the cost and benefits of therapeutic agents than your doctor does. There are many therapeutic agents that are basically the same, except for expense. Most of the information your doctor receives is biased, and is often presented in a manner (i.e., a lunch funded by reps) that is intended to manipulate his prescribing habits and instill doubts about less expensive drugs, especially generics. Manufacturers hate generic drugs.
And if you fall into a category where drugs are not the same — like certain SSRIs really don’t work for some people while others do, you should be able to get the one you need at a lower copay level.
Having said all that — it’s way too complicated for the average person to understand.
P.S. Step Therapy is often used where it is considered that a lot of inappropriate prescribing takes place, for instance, using SSRIs for someone who has suffered acute loss rather than true depression. There are actually a lot of people who go to a doctor and request specific products, like Prozac in the belief that it is a “happy” drug, instead of a drug that makes chemical changes in your brain. It would be helpful if someone invented a test to determine when SSRIs can make a meaningful difference, i.e., when you actually have the chemical issues for which SSRIs provide relief. But to the best of my knowledge, there is no such test.
Just to clarify, whatever else is wrong with Part D, the plan is not permitted to change the formulary at any time.
From what I have read, they can change it anytime, but must give consumers 60 days notice.
The step program also applies to people who have been using a particular drug successfully for some time, doesn’t it? With SSRIs and medications for mental illness, for example, that seems particularly burdensome since they can take weeks to show whether they help or not. If someone is mentally healthy now because they’re on a successful medication, it seems incredibly cruel to make them go through step therapy for months.
Blue, it’s true that the regulations might say that the plan can change the formulary, but I believe that CMS has, as an agency, imposed a moratorium on such changes for the rest of the year. Better protection in this regard is definitely needed, BUT, and I think this is important, most reputable plans don’t make a lot of changes year to year. One problem with Part D is that it is something of a free for all attracting plans without a lot of experience in pharmacy benefit management, for reasons I won’t bother to go into on the grounds that you will wonder how I manage to get through a day without gnashing my teeth as a result of technocratic induced psychosis.
Step therapy rules depend totally on the plan — but in any case, all plans are required to have an exceptions process. I take it that you might be among those who are called dual eligibles — and as a group, you have probably been disadvantaged by Part D more so than any other class. That, to my mind, is the real problem with Part D — throwing an incredibly complex benefit at very vulnerable people. And it is complex — you shouldn’t need to have my expertise to figure it out.