If you have got a Medicare Part D prescription drug plan and are taking a number of brand-name medications – especially expensive ones – there’s probability you will have difficulty covering the prices.
Even worse, based on two recent studies, there was a big increase within the likelihood that your plan will inform you that you just either cannot get an expensive brand-name drug because it is not on the “formula list” or that prior authorization is required.
And that could be detrimental to your health, considering that folks with Medicare Part D plans take a mean of 4 or five prescription medications per 30 days.
Medicare restrictions often apply to brand-name medications
“When it comes to branded products, almost seven out of 10 products are either restricted or excluded. That’s pretty high,” says Geoffrey Joyce, director of health policy at the USC Schaeffer Center, citing data from the March 2024 Health Affairs article he co-authored: “Medicare Part D Plans to Significantly Tighten Use Limits on Prescription Drugs, 2011-20.”
Joyce and his colleagues found that restrictions in Part D plans (what the plans call “utility management”) increased dramatically between 2011 and 2020 for each traditional Medicare plans and personal insurers’ Medicare Advantage plans. In 2011, 21% of the medications they reviewed had limitations. In 2020 it was 44%.
Sometimes the plan’s list of covered drugs (called a formulary) didn’t include certain prescriptions. This was more true for traditional Medicare Part D plans than for Medicare Advantage Part D plans.
The three largest pharmacy profit managers excluded 1,356 medications for no less than one 12 months from 2019 to 2022, based on a study by Pembroke Consulting.
Prior authorization, step therapy and exclusions
In other cases, beneficiaries were required to take a prescription much like the one they requested before receiving the prescription they and their doctors preferred, a practice often called step therapy.
In many cases, patients needed prior authorization: their doctors needed to prove that the drug was medically essential under their Part D plan to ensure that them to receive reimbursement.
Health insurers need to “steer patients and physicians toward what they perceive to be lower-cost and lower-cost therapies,” Joyce says. “So in theory it’s not necessarily bad.”
Formulation exclusions prevent “all but the few who successfully appeal or can afford to pay out of pocket from receiving a restricted drug when prescribed by their doctor,” the article in Health Affairs says.
Zarek Brot-Goldberg, a professor of public policy on the University of Chicago, says a 2023 National Bureau of Economic Research (NBER) study he and Harvard Medical School conducted Researcher The study conducted found that between a fifth and 1 / 4 of all prescription drug spending between 2007 and 2015 required prior authorization.
Jumping through hoops
“If you’re taking a really expensive drug, you have to get prior authorization,” Brot-Goldberg says. “You would never want prior authorization for things like statins and beta blockers, which are cheap and everyone should get them. These don’t often have prior approval.”
But some people need expensive medications and “we let them bounce around,” he noted.
In Brot-Goldberg’s study, all Part D plans had some prior authorization, but each plan targeted different drugs.
More than 60% of family doctors questioned The time spent getting patients the medications or treatments they need due to insurance restrictions is a “major” problem, based on the Commonwealth Fund health research group.
“You talk to doctors and they say, ‘I want the full range of related medications available to my patients,” Joyce says. “If drug A doesn’t work, I want to switch her to B and then to C. But I can’t do that with a lot of these plans.”
Things could get even worse in 2025
Leigh Purvis, director of prescription drug policy at AARP, believes the $2,000 annual cap on Medicare prescriptions that goes into effect in 2025 could lead on to further restrictions on prior Part D plan approval.
“I think there is a possibility that plans could change their formulas and potentially become less generous because of the costs they face,” she says.
Already, many prescribed drugs advertised on television — resembling Eliquis, Xarelto, Trulicity and Enbrel — can cost Medicare recipients 1000’s of dollars.
Prices for a few of these drugs have risen far faster than the speed of inflation.
A 2023 report from the AARP Public Policy Institute found that list prices for the highest Medicare Part D drugs have increased a mean of 226% since they got here onto the market. The average price of latest prescribed drugs approved by the Food and Drug Administration is over $200,000.
The Problem for Low-Income Medicare Recipients
The NBER paper found one other problem with Part D prior authorization for eligible individuals Medicare subsidy for low-income earners.
When these beneficiaries hadn’t enrolled in a Part D plan and Medicare randomly assigned them to a free version, the researchers found that half of them needed to get a unique but related drug and the opposite half needed to get the prescription altogether rejected.
But many low-income Medicare recipients who learned on the pharmacy that they needed prior authorization to acquire the same drug never took the suitable steps and ended up not taking any medication for his or her health problem in any respect.
An inefficient system
“Prior authorization is not managed in the most efficient way,” Brot-Goldberg says. “What should happen is that the patient should go back to their doctor and ask them to submit a prior authorization request.”
Instead, he noted, they often turn into discouraged and do not care.
“It’s puzzling because you would think that many of these people have chronic illnesses that should be examined by doctors,” Brot-Goldberg added. “In all this, where are the doctors who are putting patients on these medications?”
Harm to Medicare Patients
It is difficult to say how much harm delays in Part D prior authorization cause to Medicare beneficiaries because there’s little data. “I don’t think we really have an idea of how bad this is,” Brot-Goldberg says.
However, in a 2022 American Medical Association survey, a couple of third of 1,011 physicians surveyed said prior authorization had resulted in a serious hostile event for a patient.
Joyce says that when he and his colleagues studied individuals with Part D plans who were told they’d to take the generic blood thinner warfarin as a substitute of costlier brand-name alternatives for Medicare coverage, “we showed some higher rates of stroke.”
Joyce’s research team is just not studying whether patients with MS have health problems because they can’t get the medications prescribed by their doctors.
An October 2023 Journal of the American Medical Association study found that about 15% of cancer patients whose medications required prior authorization experienced treatment delays of greater than 4 weeks because of this; almost 40% waited one to 4 weeks.
“Dealing with pre-approval issues adds an additional layer of stress, which is known to increase anxiety and can worsen treatment- and disease-related symptoms and side effects,” the study authors wrote.
Frequent formula changes
Part D prescription drug plans can and do change their forms and prior authorization rules at any time. Just because your Part D plan covers your expensive medications now does not imply it’ll in the longer term.
“There really is a lot of change from year to year,” Purvis says. That frustrates Medicare recipients, Joyce noted.
The Biden administration has begun cracking down on preauthorization in Medicare Advantage plans and setting deadlines for delays. Some states have also enacted prior authorization laws that exempt certain physicians in Medicare Advantage networks from licensure. Some major health insurers say they’re working to cut back preauthorization requirements for Medicare beneficiaries.
In a number of states, prescription drug affordability panels have tried to limit the associated fee of certain drugs, despite objections from pharmaceutical corporations.
Advice on avoiding Part D prescribing problems
So what can individuals with Medicare Part D plans or those that need to enroll do to be certain that the medications their doctors want them to take are covered?
Start by diving into Medicare online Plan Finder Tool to aid you see how each Part D plan works and compare alternatives.
“During Medicare open enrollment [generally October 15 to December 7]“You really need to look at the Part D plans available to you and find out if the medications you’re taking are subject to utilization management,” Purvis says. (People eligible for Medicare’s Low-Income Subsidy can switch to Part D plans at any time.)
Even if you have got a Part D plan, read the newest documents online because the foundations for what part is roofed could also be different than if you signed up.
If you utilize Plan Finder, you will probably need to spend time determining the prior authorization rules and what medications are included within the plan’s formulary.
Brot-Goldberg did this for his father last 12 months when he first signed up for Medicare.
“I avoided my father getting prior authorization for any of his medications,” Brot-Goldberg says.
But, he adds, researching it was difficult. “And I’m an expert.” He will undergo the method again next month for his mother.
You may call yours State Health Insurance Assistance Program, often called SHIP. Here, knowledgeable staff and volunteers can answer your Medicare questions and guide you thru the Part D puzzle.
The Part D appeals process
If your Part D plan denies you coverage for a drug, you possibly can try it appeal.
The process could be cumbersome and stressful, but it surely could lead on to a reversal.
“They tie you up and make it difficult,” says Joyce. You have to make a stronger medical argument than simply saying your doctor wanted you to take the drug, he notes.
