Press Release             

FOR IMMEDIATE RELEASE
Contact: Deane Beebe
Communications Director
212-204-6219
E-mail
Medicare Rights Center

September 28, 2006

Medicare Private Drug Plans’ Utilization Restrictions on Mental Health Drugs Disrupt Treatment Regimens, Study Finds

Centers for Medicare and Medicaid Services Allows Plans to Restrict Drugs Based on Cost Not Clinical Recommendations

New York, NY - Commonly prescribed antidepressant and antipsychotic medications are often subject to restrictive “utilization management techniques” by Medicare private drug plans, impacting people already stabilized on these medications who should be exempted according to guidelines from the Centers of Medicare and Medicaid Services.

Private plan restrictions on mental health drugs vary widely from plan to plan and drug to drug, with a 23 percent average prevalence on antidepressant and antipsychotic medications, and as much as a 44 percent prevalence on these drugs in some plans, according to a study by the Medicare Rights Center, a national consumer service organization. Utilization management includes prior authorization requirements, quantity limits and step therapy.

"It is a cruel and devastating hoax to impose insurmountable hurdles between people with mental illnesses and the medicines they need to have decent lives,” said Robert M. Hayes, president of the Medicare Rights Center. “CMS should outlaw these barriers to health.”

In “Clearing Hurdles and Hitting Walls: Restrictions Undermine Part D Coverage of Mental Health Drugs,” the Medicare Rights Center finds:

  1. Not all plans meet the “all or substantially all” coverage benchmark. Use of utilization management restrictions varies widely and is often without clinical rationale.
  2. Plans do not consistently impose utilization management restrictions on drugs contraindicated for use in older adults.
  3. Individual plans impose utilization management techniques differently on multi-source brand names and corresponding generic alternatives.
  4. Commonly prescribed drugs had higher rates of utilization management.
  5. More expensive drugs had higher rates of utilization management.

To ensure that people with Medicare are not denied access to medicines that are crucial to their mental health, the Medicare Rights Center recommends that CMS take the following steps:

  1. Subject all formularies to a rigorous review to ensure compliance with the “all or substantially all” standard.
  2. Review all utilization management restrictions to ensure they are clinically sound and are not designed simply to steer patients to low-cost alternatives that are medically inappropriate.
  3. Require that all Part D plans have the means to distinguish at the point of sale, both for current and new members, between prescriptions for newly initiated therapies and prescriptions for patients already stabilized on a medication regimen.
  4. All utilization management techniques should be enforced through dialogue with prescribing doctors not through denied access at the pharmacy counter.
  5. Reassignment of dual eligibles and other recipients of the Part D low-income subsidy program (Extra Help) to below-benchmark plans should ensure that drug regimens will not be interrupted under the plan assigned for 2007.

As many as one in five older adults and over half of people with Medicare because of disability have a mental or cognitive impairment. Older adults have the highest suicide rate in the United States.

More information on the study’s scope and methodology, findings, and conclusions and recommendations can be found in Clearing Hurdles and Hitting Walls: Restrictions Undermine Part D Coverage of Mental Health Drugs

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