Medicare Rights Center Applauds Senate and House Members for Raising Part D Appeals Concerns
— Letter to CMS Acknowledges Beneficiary Burdens, Outlines Needed Improvements —

New York, NY—Today Senate and House cosponsors of the Medicare Part D Beneficiary Appeals Fairness Act (S.1365 and H.R.2827) wrote to the Centers for Medicare & Medicaid Services (CMS) to demand greater transparency from the agency on the Medicare Part D appeals system as well as critical steps to ease beneficiary confusion and barriers to accessing needed prescriptions denied at the pharmacy counter.

This bipartisan letter was spearheaded by the chairman and ranking member of the Senate Special Committee on Aging, Sens. Bill Nelson (D-FL) and Susan Collins (R-ME), along with U.S. Reps. Hank Johnson (D-GA), Jan Schakowsky (D-IL), David McKinley (R-WV) and Keith Ellison (D-MN). The letter explains the limited amount of data publicly available on how well Part D plans manage the appeals process and requests that CMS release a meaningful analysis on these appeals while also re-categorizing data collection on specialty tier medications. Under the current appeals system, beneficiaries refused medicine at the point of sale must, with the support of their doctor, request a formal coverage determination (essentially proof of a denial) through a written request to the plan. The letter also asks CMS to simplify this process and ease beneficiary confusion by allowing beneficiaries to receive that coverage determination at the pharmacy.

“The Part D appeals system is in desperate need of repair,” said Joe Baker, President of the Medicare Rights Center. “Each year, the Medicare Rights Center answers more than 15,000 calls on our national helpline. Over one third of these calls come from seniors and people with disabilities denied a medication or health care service, and too often these callers are beneficiaries who leave the pharmacy empty-handed and with nowhere to turn. The current Part D appeals process is bogged down by needless steps that translate into delayed access to medications for beneficiaries, threatening their health and well being and putting them at greater risk for ambulance rides, emergency room visits and hospital stays.”

Finally, the letter urges CMS to revisit its cost threshold for allowing drugs to be placed on specialty tier formularies. Released in the 2015 call letter, CMS again proposes to allow drugs that meet an unreasonably low cost threshold—$600— to be placed on plan specialty tiers. This threshold has not been reassessed since 2008, despite the rising costs of specialized prescription medications.

Baker concluded, “When a medication is placed on specialty tier it can be ruinous for Medicare beneficiaries, because it often hikes beneficiary cost sharing. Many of our callers simply cannot afford the copayments for these high-cost prescription drugs. With no right to appeal for lower cost sharing, many seniors and people with disabilities go without the medicines they need.”

The Medicare Part D Appeals Fairness Act, championed by Senator Nelson and Congressman Johnson, would allow beneficiaries to request lower cost sharing for specialty tier drugs through an appeals process called a tiering exception. This reform and those noted in the letter to CMS are critical to promoting the health and well being of people with Medicare.

Read the letter.

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