PHILADELPHIA — Physicians can help Medicare beneficiaries who are trying to select a Medicare drug coverage plan, but they have to make sure they follow all the rules, Charlene L. McGinty said at the annual meeting of the American Health Lawyers Association.
The drug benefit, also known as Part D, was passed by Congress in 2003 and became effective in January 2006. Patients pay an annual deductible of $250 as well as a premium of about $35 per month, depending on the plan they choose. The plan then pays 75% of drug costs until the patient has spent $2,250. After that, in most plans, the patient has to pay the next $3,850 out of pocket; this period is known as the “doughnut hole” or “coverage gap.” Once the beneficiaries' bills hit $5,100, the plan pays 95% of any remaining drug costs for the rest of the year. Low-income beneficiaries receive a more generous benefit.
Drug plans are administered by private insurers, but of all the plans participating, 20 plans represent 90% of the market, said Ms. McGinty, a partner in an Atlanta law firm. “The biggest group is [affiliated] with UnitedHealth Group,” she added. There are 10 “national plans” approved by the Centers for Medicare and Medicaid Services; those plans are recommended for snowbirds who live in one place during the spring, summer, and fall but go south or west for the winter.
To help beneficiaries navigate the maze of plans, physicians are allowed to do certain things, Ms. McGinty said. She recommended asking patients the following questions about the plans they're considering signing up with:
▸ How much is the deductible—the standard $250, or less?
▸ What about copays? Does the plan require a set copay or does it charge “coinsurance,” which means the patient must pay a certain percentage of the drug cost, whatever it is?
▸ Which pharmacies are included in the plan's pharmacy network? “Many seniors have established relationships with pharmacies and pharmacists,” said Ms. McGinty. “They may not want to change them.”
▸ What is in the formulary? Are the patients' drugs covered, or will they have to go through prior authorization or step therapy before they can get their particular medications?
One audience member pointed out that although plans are supposed to review their formularies once every 180 days, their pickup of drugs approved in 2005 was “unbelievably poor.” If the plans base their formulary decisions on the model formulary published by the United States Pharmacopeia, that formulary is updated only once a year, he noted.
Ms. McGinty agreed that “there is a potential lag” to the new drugs coming on the model formulary, but added that each plan's pharmacy and therapeutics committee also is supposed to be keeping tracking of new drug approvals and deciding whether to add a new drug.
Off-Label Drug Use
Plans are supposed to approve off-label use as long as the use is listed in one of three drug compendia, said Greg Jones, who is with the program integrity group at the Centers for Medicare and Medicaid Services. But trying to help a patient get a drug for an off-label use not listed in a compendium will be a “trouble spot” for doctors, he conceded.
Although providers can give patients some help in choosing a drug plan—and even help low-income beneficiaries fill out the paperwork to get better benefits—“tension exists because there are limitations on what providers can say” about various drug plans, Ms. McGinty explained. For example, providers cannot make specific plan recommendations, they can't steer an undecided enrollee to one plan over another, and they can't accept plan applications.