{"id":2692,"date":"2006-09-08T14:26:01","date_gmt":"2006-09-08T21:26:01","guid":{"rendered":"http:\/\/www.amptoons.com\/blog\/archives\/2006\/09\/08\/part-d-drug-formulary-quirks\/"},"modified":"2006-09-08T14:26:01","modified_gmt":"2006-09-08T21:26:01","slug":"part-d-drug-formulary-quirks","status":"publish","type":"post","link":"https:\/\/amptoons.com\/blog\/?p=2692","title":{"rendered":"Part D drug formulary quirks"},"content":{"rendered":"

I’m signed up for Medicare Part D, though it wasn’t by my choice<\/a>. 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<\/a> Republican politicians<\/a> 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.<\/p>\n

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.<\/p>\n

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<\/span> 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.<\/p>\n

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:<\/p>\n

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.<\/p>\n

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.<\/p>\n

All anti-HIV agents seem to be brand-name and preferred.<\/p>\n

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.<\/p>\n

All but one “blood glucose regulator” is either generic or preferred. So diabetics get better coverage than those who are bipolar, it seems.<\/p>\n

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.<\/p>\n

Cialis, Levitra and Viagra are all<\/span> preferred, though quantity limits (QL) exist.<\/p>\n

“Sex hormone modifiers” — birth control — are mostly generic or preferred. Plan B is non-preferred. Don’t tell me that’s<\/span> not political.<\/p>\n

The only “sedative\/hypnotics” listed are Ambien and the generic chloral hydrate. Ambien is both non-preferred and has a QL.<\/p>\n

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.<\/p>\n

A new Kaiser Family Foundation study<\/a> resulted in the following information about Medicare Part D:<\/p>\n

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 \u201cmost\u201d of their customers in Medicare drug plans.<\/p>\n

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\u2019s formulary.<\/p>\n

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.<\/p>\n

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.<\/p>\n

Nearly half of pharmacists (45%) who serve \u201cdually eligible\u201d beneficiaries, who were previously getting coverage through state Medicaid programs, say that these customers experienced more problems filling their prescriptions than other Medicare customers.<\/p>\n

Among doctors with patients in Medicare drug plans, 59% say that they have had patients who experienced problems getting their prescriptions, with 15% saying \u201cmost\u201d of their patients in Medicare drug plans had such problems. One in 10 (10%) say that they had a patient who suffered a \u201cserious medical consequence\u201d as a result of such problems.<\/p><\/blockquote>\n

And on the business side: <\/p>\n

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.<\/p><\/blockquote>\n

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.<\/p>\n

Crossposted at The Gimp Parade<\/a><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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 … Continue reading →<\/span><\/a><\/p>\n","protected":false},"author":9,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[106,24],"tags":[],"class_list":["post-2692","post","type-post","status-publish","format-standard","hentry","category-class-poverty-labor-related-issues","category-disabled-rights-issues"],"_links":{"self":[{"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=\/wp\/v2\/posts\/2692","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2692"}],"version-history":[{"count":0,"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=\/wp\/v2\/posts\/2692\/revisions"}],"wp:attachment":[{"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2692"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2692"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/amptoons.com\/blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2692"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}