Medicare Private Drug Plans' Appeals Process Failing, Leaving Older And Disabled Americans With Prescriptions Unfilled
March 21, 2017
New York, NY - People who appeal to get medicines that their Medicare private drug plans have deemed "off-formulary" and "restricted" find that the appeals process does not work, according to a brief released by the Medicare Rights Center.
The consumer group reports that people enrolled in Medicare private drug plans are routinely unable to secure a fair hearing despite the Centers for Medicare and Medicaid Services assurances that the federally subsidized plans are required to provide "quick" and "expeditious" determinations regarding coverage requests.
"Until these for-profit drug plans are mandated by the Administration to operate a meaningful appeals process, come April, even more older and disabled Americans will face the fiasco they experienced when the drug benefit first took effect," said Robert M. Hayes, president of the Medicare Rights Center, a national consumer service organization.
CMS extended the drug benefit "transitional period" after widespread problems with getting prescriptions filled were reported, but it expires on March 31st, as do other safeguards put into place by dozens of states on behalf of people with both Medicaid and Medicare who were transitioned to Medicare drug coverage when the drug benefit took effect.
Some of the problems people with Medicare encounter when they try to appeal for "off-formulary" drugs or those that are subject to utilization management tools, such as prior authorization, step therapy and quantity limits are: calls to private drug plans go unanswered; customer service representatives say there is no appeals process; plans fail to meet required timeframes for making decisions; and every drug plan uses its own forms and these forms are not readily accessible or require excessive backup documentation from a doctor.
The Medicare Rights Center has made several recommendations to ensure that older and disabled Americans can get their prescriptions covered by their Medicare private drug plans, including:
-- CMS should issue stiff financial penalties-including debarment from the Medicare program-to drug plans that do not comply with required appeal standards. Plans that do not deal expeditiously with appeals should lift formulary "restrictions" in order to triage the appeals.
-- For drugs in the six protected classes-immunosuppressants, antidepressants, antiretrovirals, antipsychotics, antineoplastics, and anticonvulsants -CMS should require that drug plans lift all quantity limits, prior authorization and step therapy requirements.
-- CMS should immediately implement its strengthened transition protections proposed for 2007.
"If the Bush Administration and Congressional leadership want to lower the price of the Medicare drug benefit, they should permit the Medicare program to use its bulk purchasing power and negotiate good prices with the drug companies," said Mr. Hayes. "Instead, they allow federally subsidized, for-profit drug plans to deny older and disabled Americans the critical medications their doctors' prescribed."
The Medicare Rights Center's report Medicare Part D Appeals System Breaks Down is available at medicarerights/appealsbrief_final.pdf. The group's comments on the "CMS Draft 2007 Transition and Formulary Requirements" are at medicarerights/March_6_comments.pdf .
The Medicare Rights Center is the largest independent source of health care information and assistance in the United States for people with Medicare.