Analysis of Medicare claims data reveals that Medicare Part D plans only cover about two-thirds of drugs in the ‘six protected classes,’ often excluding brands when there is a generic alternative.
Medicare prescription drug plans only provide coverage for a select group of drugs — that list of drugs they cover is commonly known as a formulary. These formularies provide plans the ability to exclude coverage of certain medications while favoring others, which they often use as leverage to negotiate discounts from drug manufacturers. These same principles apply within Medicare’s “six protected classes” of medications, even as guardrails help ensure patients with the most complex conditions (ex. mental illness, cancer, HIV, organ transplants, epilepsy) have access to a broader selection of treatments than is available under the standard Medicare benefit.
In a letter to Department of Health and Human Services (HHS) Secretary Alex Azar, House Mental Health Caucus Co-chairs Grace Napolitano (D-NY) and John Katko (R-NY) urged HHS not to move forward with harmful changes to Medicare’s Six Protected Classes Policy. The bipartisan letter — signed by 39 House members — states that the proposed changes are “particularly worrisome” for Medicare beneficiaries living with mental illness, noting that the change “directly targets” some of the program’s most vulnerable populations. “CMS has stated that patients will be able to use the lengthy appeals and exceptions processes to gain coverage for medicines if plans deny access to needed medicines,” the letter states. “However, those processes are difficult for patients to navigate and are likely to become overwhelmed with patients desperate to stay on the medicines they have been using to successfully manage complex conditions.”
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