With the coming of the New Year, it may be déjà vu all over
again for psychiatrists and their patients in the Part D Medicare prescription
Prescription drug plans have been revising their formularies, and
exceptions and approvals for prescription drugs granted in 2006 may terminate
at the end of the year. The status of prescription drug plans (PDPs) may also
change: some plans will go out of existence, requiring patients to choose new
plans, while other plans will no longer be affordable for the low-income
beneficiaries who were enrolled in them in 2006.
In the latter case, the government will auto-enroll low-income patients
into new PDPs, providing they stayed with the plan into which they were
originally enrolled at the beginning of the year, said Irvin (Sam) Muszynski,
J.D., director of APA's Office of Healthcare Systems and Financing.
But those low-income patients who changed plans in 2006 and whose plans are
no longer low-cost plans in 2007 will learn of this only when they receive
their Annual Notice of Coverage or when they get their first bill in 2007.
All of this is likely to send shivers down the spines of clinicians who
recall the near chaos that ensued 11 months ago when the new prescription drug
plan took effect.
Then, there was a tidal wave of complaints including reports that patients
were being charged inappropriate copayments, pharmacies were unable to confirm
eligibility in the program, and drug plans were failing to have mandated
transition policies in effect for the 6 million "dual eligibles"
who ceased having their prescription drugs paid for by state Medicaid programs
and began coverage under the new Medicare program on January 1.
So severe were the problems that by February half the states and
Washington, D.C., had taken emergency action to continue prescription drug
coverage under state financing until problems with the new federal program
could be fixed (Psychiatric News, February 3).
In January Andrea Stone, M.D., medical director of Carson Center for Human
Services in Westfield, Mass., told Psychiatric News that many
patients had been informed that they needed prior authorization for
medications even though PDPs were supposed to have transition plans for dual
eligibles to circumvent the need for prior authorization. In other cases,
patients had been informed that the pharmacy could not confirm their
enrollment in a plan at all.
"So far it has been stress, confusion, and pandemonium," she
said at the time.
Now, Stone says many of the problems originally encountered in January have
been resolved. "The kinks seem to have been worked out," she told
But not all clinicians report the same satisfaction. Muszynski said high
copayments continue to be charged to low-income subsidy (LIS) patients, most
of whom have income between 135 percent and 150 percent of the federal poverty
level. These patients can have copayments as much as 15 percent of the drug
Availability of benzodiazepines and barbiturates—which are precluded
from coverage by statute—also continues to be a problem. "There's
some good news on that front in that several plans have indicated that they
will cover those drugs," Muszynski said. "united Healthcare has
made it known that under its enhanced formulary, it will cover benzodiazepines
Another problem is the time physicians must spend pursuing appeals and
exceptions (see box at
"The amount of time and level of knowledge necessary to navigate the
system is beyond the scope of the average beneficiary or physician,"
Muszynski told Psychiatric News. "The notion of beneficiary
protection is more on the illusory side than on the real side. The average
psychiatrist may admit one to four people a week, but the same psychiatrist
may write 10 to 20 scripts a day.
"The amount of uncompensated time spent by doctors getting prior
authorizations is a significant problem," he said.
Finally, authorization for off-label use of drugs remains a major problem
for clinicians, Muszynski said.
According to CMS, there were 19 major PDPs as of April that covered at
least 1 percent of the covered population in Medicare; each of these parent
companies may offer plans under as many as four or five different plan
The top five companies are UHC-Pacificare, which enrolled 27 percent of all
beneficiaries; Humana, enrolling 18 percent; Wellpoint, and Member Health,
each of which enrolls 7 percent; and WellCare Health Plans, which enrolls 6
percent of beneficiaries.
A total of 38 million beneficiaries received some kind of drug coverage as
of June. This included 10.37 million in stand-alone PDPs; 6.04 million in
Medicare Advantage plans with prescription drug coverage; 6 million dual
eligibles who are automatically enrolled in drug coverage; 6.90 million
receiving a Medicare retiree drug subsidy through the Medicare program; and
3.46 million receiving drug coverage through either the Federal Employee
Health Benefits program for retirees, or the military's TRICARE program for
About 5.38 million people receive coverage through other programs such as
the Veterans Administration or the Indian Health Service.
Now, with the approach of the New Year, the deck may be reshuffled all over
"There are certainly some people who have benefited from the new
program and some for whom it works well," psychiatrist Elizabeth
Delasante, M.D., of Baxter, Minn., told Psychiatric News. "But
I really dread what January will bring because it could be a repeat of last
Muszynski told Psychiatric News that clinicians should prepare for
three broad changes that can affect their patients: change in the status of
PDPs, changes in drug formularies, and the expiration of exceptions and
approvals that were granted in 2006.
"When we look ahead to the 2007 plan year, the prognosis for how much
things have improved is going to be tested in the days ahead," Muszynski
said. "The people who may have problems are those whose plans have
changed. There will be two kinds of plan status change—one is that the
plan is no longer in existence and the other is that a low-premium plan may no
longer be low premium."
In that case, patients should have received a notice by this time and will
be auto-enrolled into a new low-premium plan—providing they stayed in
the plan into which they were originally auto-enrolled in 2006. If they
changed plans, they will not receive a notice and will not be auto-enrolled;
they will likely only learn that they owe a small premium when they receive
their first bill in 2007.
He said that formularies are not expected to change drastically, but
cautioned that experience will vary, and there may be individual cases in
which substantive changes occur in available drugs. He added that CMS has
improved its "formulary finder"—the government's online tool
that had encountered significant problems during the program's first year.
"Another test of whether things have improved will be the success of
the formulary finder and whether plan information on PDP Web sites is
reliable," he said. "These are all access to information tools
without which you are traveling blind."
In addition, exceptions granted by PDPs in 2006 may have to be renewed in
2007. But Muszynski said APA has been working with major insurers and reports
that some of those plans may grant automatic extensions to exceptions granted
Finally, Muszynski said another key test will be CMS's transition policies
for patients who move into a new plan. Last year, patients moving from the
Medicaid program to the new Part D program were expected to continue receiving
prescribed drugs during the transition period; frequently that didn't happen,
and patients sometimes left the pharmacy without their medications.
This January, that's not supposed to happen. "CMS has said that the
PDPs have attested that they have met the requirement [for having a transition
policy in effect]," Muszynski said. "This time if they fail,
corrective action should be taken."
Muszynski urged clinicians seeking information about these and other
possible changes to go to<www.mentalhealthpartd.org>
for guidance (see box at
left) and to contact the Office of Healthcare Systems and Financing at (866)
882-6227 with questions and problems. ▪