Rules of Medicare Drug Plans Slow Access to Benefits

[Judi Lynn]

Rules of Medicare Drug Plans Slow Access to Benefits

By ROBERT PEAR
Published: February 14, 2006
WASHINGTON, Feb. 13 — Doctors and pharmacists say many drugs theoretically covered by the new Medicare drug benefit are not readily available because of insurers' restrictions and requirements.

The benefit is administered by scores of companies under contract to Medicare. Each plan has its own list of covered drugs, known as a formulary. Drug plans require doctors and patients to obtain "prior authorization" for certain drugs on their formularies.

The procedures vary by plan. One plan may have 25 or 30 forms for prior authorization for different drugs. Most states have at least 40 Medicare drug plans.

Doctors say the diverse requirements are onerous and can delay or deny access to needed medications. But insurers say the requirements save money and promote the proper use of the medications.

Dr. Jeffery A. Kerr, who cares for hundreds of older patients in southern Missouri, said: "Medicare drug plans have created significant hurdles that patients and physicians must jump over before getting their medications. The prescription drug plans are playing a dangerous game. In many cases, we're dealing with frail, very vulnerable individuals."
(snip/...)

http://www.nytimes.com/2006/02/14/politics/14medicare.html

[Gloria]

1. I'm still trying to figure out what a "tier" is...in one plan I looked at,

drugs were covered in "tiers"--I assume it relates to the amount of $$ actually covered for that drug. I guess. But I don't know, therefore, I don't sign.....

[juajen]

2. Mr. juajen hasn't signed up yet

It's too confusing. He doesn't have to, does he?

[sandnsea]

3. No, but

I'm not sure he'll get any drug benefit at all if he doesn't. Not unless he has a good plan through his retirement. A friend of ours does and was told to just stick with that and his traditional medicare. I hope that's right because the whole thing is very confusing.

[salin]

7. Many retirement plans dropped drug benefit coverage

telling folks that they *had* to use Medicare Plan D instead, or not have any drug coverage.

[sandnsea]

8. I worry about them all

Lots of old folks where I live. The one couple are PG&E and Cal State retired, so I think they're okay for now. But I know how things are changing so fast. Republican voters, her for the religion and him for the tax cuts. But then she turns around and gets very upset about women's rights and him about medical costs, they used to live in Canada and he's always talking about their great free health care. People are weird. But I do hope their medical works out okay for them.

[salin]

10. Don't be too comfortable

retirees from Indiana University got kicked off their prescription coverage. Mind you IU and Bloomington are pretty liberal to begin with (even for California standards.)

Folks sometimes stop holding cognitive dissonance when the policies (and incongruities) start hitting them too directly. Check back in a year or two - wonder if they will still be clinging to GOP when voting.

[Sgent]

4. Some thoughts

If your employer continues to offer retiree perscription drug coverage -- keep it. In all cases it will be as good or better than any perscription drug plan (must be by law to get federal subsidy).

I recommend that everyone else sign up for a minimum of a Medicare Supplement (Plans A-F), and a drug plan of some sort.

If you have low perscription drug costs (less than 1-2K /yr), I in GENERAL recommend that you sign up for the least expensive Part D plan -- which can be had for as little as $12/month.

If your drugs current cost between 2-6K / yr, this is where being picky and making sure you get the exact correct plan can really payoff. Anything over 6K should essentially be treated the same by all plans.

Avoid anything with the words "Medicare Advantage" or Medicare Plus. Unless you know EXACTLY what you are doing. These plans take the place of both your Part D benefits -- and ALL OF YOUR MEDICARE BENEFITS. This means that you will be regulated to in network physicians, network hospitals, etc. There are some reasonable options out there (Kaiser comes to mind), but I would make sure you know exactly what your doing.

In short:

Good -- Medicare Plans for Part A & D
Good -- Part D plans, choose cheapest to avoid later jacking of premiums and deductible unless your total current out of pocket drug costs exceeds 2K / yr.
Good -- Medicare Supplement Plan A-F (this is the traditional supplement which pays for hospitalization beyond 90 days in a lifetime, Part A deductible, etc.

[REP]

5. I'm Kaiser Senior Advantage

Yes, I'm 41 but I'm disabled, so I'm on the Old Folks Plan. Anyway, I was Kaiser regular group before and I'm Kaiser SA group now, and I give high marks NoCA region).

[Sgent]

6. Everything I've read in the professional

literature is fairly positive on Kaiser.

Conversely, Humana has sold the crap out of their Medicare Advantage plan in this area -- and the nearest physician that accepts it is 100 miles away (nearest hospital is 75, but none of their physicians do).

[salin]

9. I encourage folks to read the whole article:

Dr. Steven A. Levenson of Towson, Md., president-elect of the American Medical Directors Association, which represents doctors who care for nursing home residents, said, "We have seen signs that Medicare drug plans are using management controls to deter access to medically appropriate drugs, including drugs on their own formularies."

Culture of Life folks... this is their so-called "Culture of Life" -
Further down in the article:

In the last year, the administration repeatedly assured beneficiaries that they would have convenient access to "all medically necessary drugs," though it gave insurers some leeway to define medical necessity.

Er... guess that little caveat might lead to definition tied to costs?

[area51]

11. "...we're dealing with frail, very vulnerable individuals."

Well, this is a republinazi attempt to cull the population.

[Flubadubya]

12. I believe this Rethug Medicare plan is deliberate...

for making it difficult for the elderly and disabled to access it. They couldn't care less about whether it helps the general population. It was not written with them... it was written for Big Pharma. Period.