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News of the Day ... In Perspective

11/01/2005

Medicare drug plans may leave patients without their medications

Even if a drug is on a plan’s formulary, a Medicare beneficiary may not be able to get it under the new Medicare Part D benefit. Patients may not discover this until they take their prescription to the pharmacy, at which time they will be locked into the plan for a year.

The formulary is only one of the cost-containment tools that a plan may use to restrict access. Others include prior authorization, step therapy (or “fail first” policies), and quantity limits that may result in denials or critical delays in receiving medications.

The tools posted at www.medicare.gov are incomplete and may be misleading, according to the American Society of Consultant Pharmacists. ASCP has developed a document that explains the restrictions to medication access, posted at www.ascp.com/MedicareRx/docs/ASCPPartDMedAccess.pdf.

Coverage of some drugs is excluded by Congress (e.g. barbiturates, benzodiazepines, nonprescription drugs). There are restrictions on all drugs in certain classes, including statin drugs, proton pump inhibitors, angiotensin II receptor antagonists, Alzheimer’s disease drugs, osteoporosis drugs, agents for benign prostatic hypertrophy, and many others.

“Physicians will also experience a tremendous administrative burden with the advent of Medicare Part D. They will be expected to contact Part D plans routinely for prescribing commonly used medications for Medicare beneficiaries. This heavy administrative burden could result in many physicians leaving the Medicare program, further exacerbataing the general lack of access to physicians experienced by many Medicare beneficiaries,” writes Thomas R. Clark, Director of Policy and Advocacy for ASCP.

Additional information:

“Delay the Medicare Drug Entitlement,” AAPS News, November 2005

“AAPS Tells Docs: Get Out of Medicare.”

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