Implementation of the Medicare Prescription Drug Program: Issues & Answers

On January 1, the Medicare prescription drug plan began. Soon after, difficulties were exposed with the program in two major areas: enrollment and accessing medications. People seemed surprised that these difficulties grew rather than lessened over the first few weeks. Of course, these increasing problems were simply the result of sheer volume.

Toward the end of any given year, older persons tend to stockpile their medication to take advantage of their current insurance program, and to avoid the need to go to their pharmacy during the holidays. As a result, the first week of the new program saw a lower volume, which grew as older persons’ stockpiles became depleted and the need for medications grew. This was especially felt by the frail elderly, who have a more difficult time navigating this complex system, as well as not having the financial means to pay for medication ahead of coverage by their prescription drug plan. This is why 20 states stepped up and agreed to provide coverage for their dually eligible population (Medicare and Medicaid recipients) for at least a short period of time.

ENROLLMENT

The enrollment issues fall into several different areas and include:

• Failure to enroll in a Medicare Part D plan
• Failure to be recognized in the right plan
• Failure to be recognized as being covered by the LIS

The problem with failing to enroll in a Medicare Part D plan stems from the fact that seniors have on average 45 different plans from which to choose, resulting in a confusing range of options. In addition, unlike Medigap plans that have standard plan designs allowing seniors to make like comparisons, Medicare Part D does not. Persons need to be informed that there are advantages in joining a plan through reduction in their out-of-pocket expenditures. More important, there are major disincentives to not joining, both in the form of a late enrollment penalty and being locked out of any coverage if a major need arises.

Of course, the answer to getting individuals enrolled can be addressed by making the program easier, and encouraging physicians and other stakeholders to be educated so they can pass this knowledge on to their patients. There are several bills being introduced to Congress that would work toward this by extending the enrollment period beyond the May 15 deadline. This would allow for at least one change of plan in this first year; individuals could go back to their company retirement plans if they had erred in opting out of this coverage. In addition, there is legislation to gain coverage for benzodiazepines, which, unfortunately, are one of the medications excluded from Medicare Part D coverage by law. The take-home message here is that physicians can avail themselves of educational resources that they can pass to their staff and patients to make the importance of this decision easier to understand. As mentioned, at least part of the answer to the enrollment issue (as is the case with most problems) is preparation. The failure of being recognized in the correct plan or having to pay the correct copayments requires that persons be prepared when they go to their pharmacy with their Medicaid card, if they have one, and provide all correspondence from their new prescription drug plan (PDP).

As mentioned, in some 20 states there is extended coverage by these states to the same extent that was available prior to December 31 under the Medicaid program for dually eligible individuals. Persons need to be persistent to ensure that they are only paying the correct copayment according to their coverage. If problems do arise, patients and physician practices should initially contact the plan, but quickly move to the Centers for Medicare & Medicaid Services (CMS) if needed. While CMS has an 800 phone number available 24 hours a day/7 days a week, even greater and more specific access is being provided through each of their 10 regional offices. These CMS regional offices have staff dedicated to address specific questions and problems that arise. For those problems dealing with coverage under the low-income subsidy, the best source is one’s local Social Security office or Medicaid office.

ACCESSING MEDICATIONS

Unfortunately, while issues with the enrollment plan will improve over time, the problems of accessing medications will be with us forever. This is because PDPs have incentives to limit access to medications. These plans are financially better off by limiting access to medications—even those that reduce hospitalization—because they do not have the opportunity to realize the benefit from such improved health outcomes. Instead, they benefit only from reduction in prescription utilization. These plans do have an obligation to provide medications through a transition period that covers the move from a previous covered medication to those available by the plan. These transitions include moving from Medicaid to a Medicare Part D plan coverage for the dually eligible, as well as from levels of care such as the hospital setting. Plans are responsible for providing continuity of at least one prescription for those in the community and a 90-180-day supply for those in long-term care.

But perhaps the most problematic for prescribers and their staff will be navigating prior authorizations and Appeals and Exceptions process for nonformulary medications. Part of the problem here is that many of the low-cost plans are requiring a significant number of these reviews prior to coverage. This process can be improved by first working with patients to ensure that they are encouraged to enroll in plans that provide the greatest level of coverage without restrictions.

In addition to having one’s patients enrolled in plans that provide unrestricted access to medications, writing the correct prescription at the “bedside” will go a long way in avoiding phone calls from pharmacists requesting changes in order to stay within the plan’s scope of coverage. Of course, it would be impossible to memorize every plan’s formulary or carry 45 plans’ formulary books with you to have available every time a prescriber writes a prescription. What is doable is to utilize an electronic version through Epocrates, which is available for free, both in a handheld version as well as a Web-based tool. If these electronic versions are logistically difficult, another avenue would be to develop “cheat sheets,” which would note the prescribing options within critical classes for the plans most encountered. In addition to the formulary “cheat sheets,” standardized prior authorization form letters can be developed. Since prior authorization is driven by each plan, the process varies widely, but certain questions remain constant between plans. By building one form that includes all of the information practices, one can fill out the complete form and fax it directly to the plan to gain access to these restricted medications. Obvious preparation is critical to preventing problems later. Medicare Part D is a clear example of that rule.

RESOURCES

While this is not an easy process to deal with, there are helpful resources available to help navigate through successfully to ensure that patients have access to the medications that they need:

Centers for Medicare & Medicaid Services Regional Offices https://www.cms.gov/RegionalOffices. The Centers for Medicare & MedicaidÊServices works to stay in touch with its stakeholders and the public in general through its Regional Offices, located in ten major cities across the United States and serving specific geographic areas.

Social Security Regional Offices https://www.ssa.gov/regions/

State Health Insurance Assistance Programs shiptalk.org The State Health Insurance Assistance Program, or SHIP, is a national program that offers one-on-one counseling and assistance to people with Medicare and their families.

Epocrates has made available for free all Medicare Part D formularies via their mobile and online drug references.

American Geriatrics Society: “Medicare Part D – Implications for Physicians and the Healthcare Team” https://www.cuph.org. This presentation is designed to allow participants to study and practice the concepts of Medicare Part D. This online presentation is designed for healthcare providers and is intended to supplement information for patients provided by Medicare.