One of the aspects of Medicare that gives much comfort to its recipients is the protected class policy of drugs. This policy ensures that those who need anti‑psychotics, antidepressants, anticonvulsants, immunosuppressants, cancer, and HIV/AIDS drugs will receive them continuously, as they are imperative to their health and provide stability in their lives.
The creation of these classes also helps to not discourage patients from enrolling in certain Medicare plans due to coverage and cost. The Center for Medicare and Medicaid Services (CMS) goes through great lengths to ensure that these protected drugs are included in the Medicare Prescription Drug Plans’ (PDP) formularies. This policy mandates that the vast majority of all of the drugs on the market for these six classes will be included in the Medicare plans. If they were not, then the formulary would be held back.
It is crucial that this policy exists. In 2010, 40% of Part D enrollees had at least one prescription that fell under one of the six categories. To further show the importance of them, 18% of the total spending on Part D was due to the protected drugs.*
But there is an issue.
After so much scrutiny and emphasis has been placed on these classes and their inclusion in the formularies, the cost and coverage of one of the classes has snaked its way into the shadows.
A new study by Avalere Health, a leading strategic healthcare advisory firm, found that anticonvulsants are not as desirable for Medicare patients due to their coverage. Under Medicare PDPs, Avalere found that anticonvulsants “had lower levels of coverage and fewer medicines on less expensive formulary tiers than commercial health insurance plans.”**
What does this mean? It deters beneficiaries from choosing certain plans and can limit their access to anticonvulsants due to the increase in cost that they have to cover. This could lead to significant health risks if they are not receiving these crucial medications.
But it is more serious than it appears. In 2010, anticonvulsants were the overall second most demanded class of protected drug, capturing 25% of all refills. However, the anticonvulsant Gabapentin was the most utilized drug in all the classes.*** Due to these statistics and with the study by Avalere, Medicare beneficiaries are paying more under PDPs for some of the drugs that they are using the most. Thus, there is a false sense of protection for a large part of Medicare patients that think they will be covered.
Here are the overall findings by Avalere:****
- Commercial plans had higher levels of coverage of anticonvulsants on formularies than PDPs, including more coverage of brand-name and extended release products.
- Commercial plans placed more covered anticonvulsants on lower tiers than PDPs.
- Cost-sharing on tiers one and two were higher for commercial plans than PDPs. For tiers three and four, cost-sharing was nearly level among both sets.
- For a medicine placed on a specialty tier, the difference in cost-sharing between coinsurance and a fixed copayment could be substantial. According to a recent report by the Government Accountability Office, the median negotiated price of all specialty tier-eligible drugs in 2007 was $1,100. Under a commercial plan with a $1,100 specialty drug on the highest tier, a patient would pay $79 a month on average. In contrast, a Medicare beneficiary enrolled in a PDP would pay 30 percent, or $330 a month, on average for the same medicine.
- Usage of utilization management techniques was fairly similar among PDPs and commercial plans.
*Reed, Monica. “Part D Protected Drug Class.” On Stream Media. Center for Medicare and Medicaid Services, 20 Mar. 2012. Web. <http://origin-qps.onstreammedia.com/origin/providerre/CMS/Media/1203Baltimore/transcripts/d1_02_PartDProtectedDrugClass_Reed.pdf>.
**Garland, Erica. “Avalere Study Shows That Patients with Medicare Part D Have More Access Barriers to Anticonvulsant Therapy Than Those Commercially Insured – Avalere News Room.” News. Avalere Health, 3 June 2013. Web. <http://www.avalerehealth.net/wm/show.php?c=>.