Know Your Rights

A lot of people with Medicare are finding the new drug plans do not cover the drugs they take.

Many others are signing up for plans that appeared to cover their drugs, but will soon discover that the plans require prior approval before paying for some medicines. Other plans will only pay for a covered drug if people first try another medicine and find it ineffective or harmful.

It’s frustrating to pay a premium for drug coverage and still have to pay the full cost of some of your most expensive medications. This is not what people with Medicare need, particularly those who rely on their drugs to stay alive and healthy.

Instead of a drug benefit delivered through Medicare that is comprehensive and understandable, people with Medicare must choose among profit-seeking drug plans each imposing their different restrictions on the medicines they cover.

And to make it worse, people with Medicare have rights and protections that the drug plans are not telling them.

All the Part D plans are required by federal regulation to have a transition plan in place for new plan members. Plans should provide a temporary fill of medicines that they do not cover. So on a consumer’s first visit to the pharmacy in January, she should be able to walk out with her medications, even if they are not on the plan’s formulary or subject to other restrictions.

However, most plans are keeping these transition protections under wraps. There’s no information about them on the plans’ web sites. Their customer service representatives usually don’t have a clue.

This is both unfortunate and a violation of CMS directives. The plans vary considerably in the length of time they will temporarily fill off-formulary medicines. Some will provide as little as 15-days’ worth. Others will fill a 90-day prescription.

People selecting a Medicare drug plan have a right to know this information because it directly impacts the coverage they will receive upon enrollment. The duration of the temporary fill determines how long they will have to schedule a doctor visit in order to appeal for coverage or to switch to another medicine. It’s also important for people to know about these protections so they can make sure they receive them when they go to the pharmacy. Finally, the knowledge that they won’t be cut off abruptly on January 1 will ease a lot of frayed nerves.

The Centers for Medicare and Medicaid Services (CMS) told the plans as much this spring. Plans “must” provide public notice of their transition policies, just as they make public their formularies, CMS said. These protections will be an important point of comparison among plans, particularly for people now covered by Medicaid who were randomly assigned to plans without regard to whether their drugs would be covered, CMS said.

The drug plans have largely ignored these instructions. That’s not right, but it is predictable. President Bush and Congress turned this drug program over to companies that are obligated to maximize profits, not to ensure that people with Medicare get the medicines they need.

CMS, unlike the private drug plans, are obligated to defend the public interest. So why isn’t this federal agency enforcing its own guidelines?

Drug plans should inform potential enrollees on their web sites, through their call centers and through their marketing materials of their temporary fill policies for new enrollees. CMS cannot stand idle while many private drug plans mislead 43 million Americans with Medicare.

Click here to email CMS chief Mark McClellan to get the plans in line.

Medical Record

CMS requires each Medicare prescription drug plan to establish an appropriate transition process for all new enrollees. Transition plans are encouraged to provide a one-time fill of a prescription drug excluded from the plan’s formulary in order to accommodate situations in which a customer presents a prescription he or she has previously filled but that is not on the formulary. Additionally, CMS recommends that this transition process address unplanned transitions as individuals change treatment settings due to a change in their level of care (“Ensuring an Effective Transition,” Centers for Medicare and Medicaid Services, December 2005).

Of the seven plan sponsors in California that were assigned people with Medicare and Medicaid, only one plan, Health Net Orange, currently mentions the transition protections on its web site (in the section entitled “Fine Print”). (“Drug Plans Keep Transition Protections Secret,” Medicare Watch, December 20, 2005).