Behind every Medicare Part D policy decision are patients whose health and independence depend on reliable access to the medications that work for them.That’s why Medicare’s Six Protected Classes protections are so important.
The Partnership for Part D Access has developed six new patient personas illustrating what coverage disruptions could mean for people living with epilepsy, depression, breast cancer, HIV, Parkinson’s disease psychosis, as well as a kidney transplant recipient who relies on immunosuppressive treatment.
Each story highlights the potential consequences of coverage denials, step therapy delays, or formulary substitutions, from hospitalization and lost income to earlier institutionalization or transplant rejection. They also demonstrate how disruptions can shift substantial, avoidable costs to patients, families, Medicare, and Medicaid.
Barbara’s depression has been stable for 2 years on a regimen developed with her psychiatrist. Disrupted coverage could jeopardize her health, work, and independence, and cause more than $8,500 in personal losses.Bottom line: Stable patients need stable access. #SixProtectedClasses
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For Barbara, access to effective depression treatment protects her health, independence, and ability to work.After 15 years of managing her condition, Barbara and her psychiatrist found a two-medication regimen that has kept her stable for two years. Now 65 and enrolled in Medicare, she earns approximately $26,000 annually through part-time work. A medication disruption could trigger a severe depressive episode, interfere with her work and treatment routines, and require emergency care or hospitalization. The resulting stress could also worsen her hypertension and cause metabolic complications.A preventable exacerbation could cost Medicare nearly $14,000. Barbara could experience more than $8,500 in health expenses and lost wages, nearly one-third of her annual income.Bottom line for policymakers: The Six Protected Classes policy helps Barbara and her psychiatrist maintain access to the treatment that works. Coverage denials, step therapy delays, and formulary substitutions can destabilize years of progress while shifting substantial costs to patients, families, and Medicare. #SixProtectedClasses #MentalHealth #PatientAccess
Robert’s medication controls Parkinson’s disease psychosis without worsening his mobility, helping him remain at home. Losing access could cause a fall and earlier institutionalization, costing Medicare nearly $200,000. Bottom line: Treatment access protects independence. #SixProtectedClasses
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For Robert, the right medication means being able to remain safely at home.Robert is 80 and lives with Parkinson’s disease psychosis. His current medication controls hallucinations and delusions without worsening his mobility. With support from his son and a home health aide, he has been able to maintain his independence. Switching to an older antipsychotic could worsen his motor symptoms, cause a serious fall, and accelerate frailty, potentially requiring institutional care five years earlier.A preventable fall and accelerated institutionalization could cost Medicare nearly $200,000. Robert and his family could face more than $300,000 in additional costs, including depleted family assets and the potential loss of his home. These consequences could ultimately shift further costs to Medicaid.Bottom line for policymakers: The Six Protected Classes policy helps Robert and his physicians maintain access to the medication that works. Preserving that access can delay institutionalization, protect family assets, and avoid unnecessary costs across Medicare and Medicaid. #SixProtectedClasses #Parkinsons #AgingInPlace
Sarah has been seizure-free for 3 years on a carefully prescribed epilepsy regimen. Disrupted coverage could threaten her independence, pregnancy, and health, while costing Medicare over $13,000.Bottom line: Protect access to the medications that work. #SixProtectedClasses
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For Sarah, consistent access to the right epilepsy medications protects her health, independence, and pregnancy. Diagnosed at 16, Sarah has been seizure-free for three years on a carefully prescribed two-medication regimen. Now 38 and pregnant, she could face serious consequences if a formulary change, coverage denial, or step therapy requirement disrupted her treatment. A breakthrough seizure could mean losing her driving privileges, emergency hospitalization, and rehabilitation. Uncontrolled epilepsy during pregnancy could also increase the risk of complications or miscarriage. A preventable health crisis could cost Medicare more than $13,000 and leave Sarah with approximately $3,600 in out-of-pocket costs, nearly three months of her income. Bottom line for policymakers: The Six Protected Classes policy helps Sarah and her physician maintain access to the medications that work. Protecting that access supports years of carefully managed stability and helps prevent avoidable costs for patients, families, and Medicare. #SixProtectedClasses #Epilepsy #PatientAccess
Dorothy needs 5 years of endocrine therapy to reduce her breast cancer recurrence risk. A coverage-driven switch could mean more appointments, monitoring,0 and family caregiving, plus over $6,000 in Medicare spending.Bottom line: Preserve access to the treatment that works. #SixProtectedClasses
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For Dorothy, access to her current cancer treatment helps reduce the risk of recurrence while allowing her to remain independent.Dorothy is 68 and three years post-mastectomy. She requires five years of endocrine therapy and currently uses treatments she can receive at home. A Medicare coverage change could force her to switch to an older, physician-administered infusion, creating more appointments, cardiac monitoring, and surveillance. Her adult child could also need to miss work to provide transportation and caregiving support.The transition could generate more than $6,000 in Medicare spending and nearly $4,400 in additional costs and lost wages for Dorothy and her family. It would also add time, uncertainty, and treatment burden during an already demanding cancer journey.Bottom line for policymakers: The Six Protected Classes policy helps Dorothy and her physician maintain access to the treatment that works. Preserving that access can prevent unnecessary medical costs while protecting her health, independence, and family. #SixProtectedClasses #CancerCare #PatientAccess
Jennifer returned to work after a kidney transplant and relies on immunosuppressants to protect it. Disrupted coverage could cause rejection or retransplantation, costing Medicare over $144,000.Bottom line: Protect the patient and Medicare’s investment. #SixProtectedClasses
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For Jennifer, uninterrupted access to immunosuppressive medication protects her transplanted kidney, health, and ability to work.Jennifer is 53 and returned to full-time work after receiving a kidney transplant 18 months ago. A coverage disruption could trigger acute rejection, requiring hospitalization and intensive treatment while worsening her hypertension and cardiovascular disease. If treatment failed, she could lose the kidney, require another transplant, experience a prolonged recovery, and lose income. Retransplantation could also delay care for another patient awaiting a viable organ.Even if rejection were reversed, the resulting hospitalization and complications could cost Medicare more than $21,000 and leave Jennifer and her family with over $11,000 in expenses and lost wages. If the transplant failed, Medicare costs could exceed $144,000, while Jennifer’s financial losses could surpass $33,000. Bottom line for policymakers: Preserving a functioning transplant is far less costly than replacing one. The Six Protected Classes policy protects Jennifer’s health and Medicare’s investment by supporting uninterrupted access to the medications that prevent rejection. #SixProtectedClasses #OrganTransplant #PatientAccess
Michael has remained virally suppressed for 5 years on effective HIV treatment. A 4-week coverage gap could cause severe illness, drug resistance, and preventable transmission, costing Medicare and Medicaid over $330,000. Bottom line: Protect uninterrupted access. #SixProtectedClasses
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For Michael, continuous access to effective HIV treatment protects both his health and the health of others. Michael is 55 and has lived with HIV since 1998. His treatment has kept him virally suppressed for five years, meaning his disease is controlled and cannot be transmitted. With an annual income of approximately $18,000, however, he cannot afford an unexpected coverage gap. Even a four-week treatment interruption could cause viral rebound, severe infection, hospitalization, and drug resistance requiring more complex care. During an undetected rebound, Michael could also unknowingly transmit HIV to a partner. These consequences could cost Medicare and Medicaid more than $330,000 and impose nearly $58,000 in additional costs on Michael and others. Most of these costs would result from severe illness, drug resistance, and a preventable new HIV infection, not the temporary coverage gap itself. Bottom line for policymakers: The Six Protected Classes policy helps Michael and his physicians maintain access to the medication that works. Protecting uninterrupted access preserves years of viral suppression, helps prevent transmission, and avoids high personal and public costs. #SixProtectedClasses #HIV #PatientAccess
