Study Shows Part D Plans Ratcheting Up Restrictions on Coverage

[Duaine]

A new study from University of Southern California (USC) researchers shows that Medicare Part D plans have been increasingly restricting access to some prescription drugs through the years. Plans have used prior authorization, step therapy, and formulary restrictions to curb beneficiaries’ ability to take certain important prescriptions. The study covered 10 years, from 2011 to 2020, and showed plan adoption of each of these utilization management practices steadily gaining traction.

Plans can exclude some drugs from their formularies entirely, meaning enrollees either must pay out of pocket or try to get an exception by submitting an appeal to the plan. In 2011, plans excluded 20.4% of drugs. By 2020, that number was up to 30.4%, with an even higher 44.7% for brand-name drugs.

Even if drugs are on the formulary, plans can limit access. For example, prior authorization requires prescribers to get plan permission before it will cover a drug, and step therapy requires patients to use one or more other drugs before gaining access to the prescribed drug. In 2011, plans subjected 11.5% of drugs to prior authorization or step-therapy restrictions. By 2020, that number had reached 14%, with a higher 23.7% for brand-name drugs.

[EXTERNAL LINK] - Study Shows Part D Plans Ratcheting Up Restrictions on Coverage - Medicare Rights Center

 

[somarco]

Not surprising.

Part D regulations are squeezing carrier profits. From all appearances, many PDP carriers are in the market for the sole purpose of converting policyholders to more profitable MAPD plans.

Expect more shrinkage and no commission plans.

 

[sshafran]

Maybe we can curb the over medicating of American seniors by PA and rising cost sharing.

All good things.

 

[sshafran]

Maybe we can curb the over medicating of American seniors by PA and rising cost sharing.

All good things.

Had a lady come in recently who was talking about how "people take so much medication" but she was thrilled that she was not one of them.

Her list was 5 Rx's. Five!

We're in a sad place if five is "not a lot."

It's like McDonald's. Rarely will people get a single hamburger and small fry - but that was normal a few decades ago.

We are slowly boiling frogs.

 

[somarco]

Maybe we can curb the over medicating of American seniors by PA and rising cost sharing.

No doubt, roughly 70% of chronic conditions are self induced (lifestyle, diet, etc.) Probably similar numbers for cancer, heart disease.

And many of those conditions can be modified or reversed with changes.

Like you, I see a lot of folks with multiple meds, especially mental health related (anxiety, depression).

Many conditions are not self induced, genetic or caused by environmental situations.

And I often shake my head but also realize too many prefer to take a medication vs making lifestyle changes.

I also have a number of clients with arthritis and other types of inflammation caused pain. In another 30 years or so, you may be in the same boat. Just sayin'

So don't cast stones . . .

 

[yankee466]

As long as it's more profitable to treat things rather than to cure them, this problem won't go away.

I remember when my primary doc plugged some of my numbers into a Pfizer ap on his phone, and said I should start taking a statin. I told him I would never do that.....went to the health food store instead...went back to the same doc in 6 months and he could not believe how wonderful all my numbers were. When he asked me how I did that, I told him it was becuase I did not listen to him.

 

[sshafran]

No doubt, roughly 70% of chronic conditions are self induced (lifestyle, diet, etc.) Probably similar numbers for cancer, heart disease.

And many of those conditions can be modified or reversed with changes.

Like you, I see a lot of folks with multiple meds, especially mental health related (anxiety, depression).

Many conditions are not self induced, genetic or caused by environmental situations.

And I often shake my head but also realize too many prefer to take a medication vs making lifestyle changes.

I also have a number of clients with arthritis and other types of inflammation caused pain. In another 30 years or so, you may be in the same boat. Just sayin'

So don't cast stones . . .

I don't really think the blame lies @ the consumer. It's @ the feet of the willy nilly doctors.

Imagine Metformin being a controlled substance. You can get it - but see that gym over there? You must check in 13 times monthly. Oh, and your apple watch needs to register an average of 9000 steps. We can't give you this until - it's a controlled substance - until we meet some specific regulations. Oh and by the way - you need this so you had better meet the criteria. Hopefully you won't need it for long. We can only give it to you for x months without serious scrutiny..... So eat ________ as well.

 

[sshafran]

I take my parents as an example. They may not be the healthiest but they also didn't get a lot of health education - so they did the best they could.

Many clients are the same way. They take 8 pills because Dr Reynolds said to. Dr Reynolds didn't say "try this first." He just gave pills. But Dr Reynolds knows better - I do blame him...

 

[goillini52]

Had a lady come in recently who was talking about how "people take so much medication" but she was thrilled that she was not one of them.

Because Big Pharma gives nice bonuses to the doctors for prescribing their drugs.

 

[somarco]

Pharma pays to promote brand name, especially the newer drugs.

They pay $0 for generics