A new study from the Partnership for Part D Access confirms that the Medicare Part D protected classes policy is an essential pillar of protection for beneficiaries with complex health conditions. Yet, the research also highlights that Medicare prescription drug plans (PDPs) are increasingly limiting access to medications — even for patients with complex, chronic conditions. The study, performed by Avalere Health, a leading strategic advisory company, provides new insights into the various steps Medicare Part D plans are taking to manage utilization of medications covered under Medicare’s six protected classes policy. The protected classes policy is designed to ensure that Medicare beneficiaries with some of the most serious health conditions — cancer, HIV, epilepsy, mental illness, and those at risk of organ rejection, among others — have access to the full range of medicines recommended by their physician.
For Medicare beneficiaries who need a specific medication that their doctor believes is necessary and most appropriate, the six protected classes policy is intended to ensure they can get it. However, even with these protections, this new research demonstrates that patients must often overcome layers of restrictive financial and administrative barriers put in place by plans intended to inhibit access to these essential medications.
According to the Avalere analysis, Part D plans are leveraging formularies and utilization management tools for Medicare beneficiaries across drugs in the protected classes. For example, in 2019, the most recent year for which data is available, plans covered just 54% of drugs across the protected classes — a decrease of nearly 20% since 2016 when the coverage rate was 67%. For covered drugs, nearly two-thirds of all medications in the six protected classes were placed in a non-preferred or specialty category, with 89% of branded products categorized as non-preferred or specialty and 37% of generics also subject to placement on the higher tiers. In aggregate, Part D plans placed drugs from the protected classes on high tiers (non-preferred or specialty) 64% of the time.
These coverage limitations are particularly concerning because of the negative impact they have on patients and their quality of life. If a patient does not receive the best treatment option, it opens the door for complications resulting in emergency department visits, physician visits, hospitalization, or other types of care that increase overall Medicare costs. Moreover, because standalone Part D Prescription Drug Plans (PDPs) are not liable for the cost incurred under Medicare Part A and Part B or Medicaid, research shows that they do not work as hard as commercial plans to ensure they offer a robust formulary. That is why Congress explicitly created fundamental patient protections — including the six protected classes policy — which are unique to Medicare and recognize the unique needs of seniors and persons with disabilities who rely on Medicare.
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