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Coverage, Not Cost Controls, for the Mentally Ill
September 28, 2006 • Volume 6, Issue 39For people suffering from schizophrenia or major depression, finding an effective drug regimen can be difficult. A psychiatrist following accepted treatment guidelines may try a succession of medicines and dosages before arriving at the combination that best alleviates symptoms, minimizes side effects and prevents a relapse.
The importance of this delicate and time-consuming process has been recognized by the Centers for Medicare & Medicaid Services (CMS), which mandated that plans cover “all” or “substantially all” antidepressant and antipsychotic drugs. Yet that mandate has been undermined by the restrictions Part D plans impose on mental health drugs, specifically antidepressants and antipsychotics.
A Medicare Rights Center survey of 15 major Medicare private drug plans in New York State found that, on average, almost one-quarter of these medicines were under some form of restriction. Plans required prior authorization before covering a drug, demanded plan members try another medicine or imposed limits on the number of pills they would cover.
Restrictions bore little relationship to accepted clinical practice: drugs that are contraindicated for use by older adults that are low-cost generics tended to be provided without restriction. But coverage of newer, higher-priced brand-name drugs was restricted by a host of measures, primarily quantity limits.
The 15 Part D plans surveyed also varied widely in how they covered these medicines. Some plans restricted access to well over one-third of these medicines, while a couple of plans allowed direct access to virtually all the medicines in these two classes. This variability is critical because in 2006 these 15 plans were randomly assigned enrollment of people with Extra Help, both in New York and in other states. And this fall, at least some of these same plans will receive random assignments of low-income people with Medicare now enrolled in plans that next year will be too expensive to qualify for a full premium subsidy under the Extra Help program.
About one million of these impoverished older adults and people with disabilities will be randomly reassigned to a new plan. Given the high incidence of mental illness among these individuals, and the strong odds that their new plan restricts coverage of mental health drugs, it is certain that many mentally ill people with Medicare will arrive at the pharmacy counter on January 1 and find out their prescription for an antipsychotic or antidepressant is not covered.
The Part D appeals system will not come to the rescue. The appeals process is a torturous nightmare for individuals who have lawyers representing them; for isolated poor people with mental illness seeing doctors already swamped with cases, it is not a viable solution. How many will stop taking their medicine and wind up in the emergency room?
CMS needs to guarantee that every person with Medicare, whether their drug plan is changed or their plan changes the drugs it covers, is able to maintain their regimen of mental health drugs at the dosages that work for them.
More broadly, CMS needs to make sure that all restrictions are based on clinical guidelines and designed to ensure the safety and health of people with Medicare. Part D plans should not restrict coverage of these critical mental health drugs in order to control costs.
The way to control costs is to have Medicare negotiate lower drug prices. And the only way to guarantee coverage of the medicines people with Medicare need is to enact a prescription drug benefit directly through Medicare. Congress is not going to do that this year; they are leaving early to campaign to keep their jobs. Our votes will decide whether they come back next year and whether some fresh faces will take a new look at fixing Part D.
Medical Record
“Ms. Z is 64 years old and has suffered from schizophrenia for over 30 years. She takes Abilify and Zyprexa to control her symptoms and has been stable for the last five years because Medicaid had covered her medications. Because she has both Medicare and Medicaid, Ms. Z was auto-enrolled in a Medicare private drug plan with her new drug coverage starting January 1, 2006. In January, Ms. Z attempted to fill her prescriptions for Abilify and Zyprexa but was told by her pharmacist that her Medicare private drug plan requires prior authorization for those drugs. Ms. Z left the pharmacy empty-handed and confused. The pharmacist had not explained what prior authorization was nor used her plan’s transition policy to fill her prescriptions. She was told by a caseworker at the medical clinic she uses that because the doctor only comes to the clinic twice a week and sees over 50 patients each day, it would be virtually impossible for the doctor to provide prior authorization” (“Clearing Hurdles and Hitting Walls: Restrictions Undermine Part D Coverage of Mental Health Drugs,” Medicare Rights Center, September 2006).
“The potential impact of impaired access to these drugs is vast. One in five older adults and over half of people on Medicare because of disability have a mental or cognitive impairment. Older adults have the highest suicide rate in the United States. People with mental illness find it more difficult than others to navigate the bureaucratic process that is required to obtain coverage for nonformulary drugs or those restricted by utilization management techniques. The frustrations and stress that accompany that process can lead patients with mental illness to abandon their medication regimens and trigger episodes of decompensation (the inability to maintain defense mechanisms in response to stress, resulting in depression, anxiety or delusions)” (“Clearing Hurdles and Hitting Walls: Restrictions Undermine Part D Coverage of Mental Health Drugs,” Medicare Rights Center, September 2006).
“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 have had a patient who suffered a ‘serious medical consequence’ as a result of such problems” (National Surveys of Pharmacists and Physicians, Findings on Medicare Part D, Kaiser Family Foundation, September 7, 2006).
***** The Medicare Rights Center (MRC) needs to hear about all the problems with the Medicare Part D benefit, whether they happen to you or someone in your community. With this information, we will be armed with the needed evidence to push for a Medicare-administered drug benefit.
Fast Relief: Part D Monitoring Project
Submit your story at www.medicarerights.org/partdstories.html
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