Part D Bill Would Protect Access to Psychotropics

A bill introduced in the House last month and supported by APA would give Medicare beneficiaries enrolled in the Part D prescription drug program improved access to critical psychiatric medications.

The Medicare Part D Drug Class Protection Act (HR 3061), which also is endorsed by patient advocacy groups and mental health organizations, would protect access to six critical classes of medications within Part D, including three classes—antipsychotics, antidepressants, and anticonvulsants—commonly used to treat psychiatric disorders.

“By requiring near-universal coverage for important classes of psychiatric medications and other medications linked with higher-than-average patient costs, the Medicare Part D Drug Class Protection Act will promote patient balance and fairness within prescription drug plans and the overall viability of the Medicare Part D program,” said APA President Carolyn Robinowitz, M.D.

The bill, introduced by Rep. Lloyd Doggett (D-Texas), would require Medicare prescription drug plan (PDP) formularies to offer “all or substantially all” drugs in six classes of medications used to treat HIV/AIDS, mental illness, cancer, epilepsy, autoimmune diseases such as Crohn's, and transplantation.

In addition, the bill would limit insurers' ability to restrict the availability of these medications.

The bill comes on the heels of findings announced by the American Psychiatric Institute for Research and Education (APIRE) that patients with psychiatric illness dually eligible for the Medicaid and Medicare programs experienced serious barriers after their prescription-drug coverage was moved from Medicaid to Medicare Part D at the start of 2006. Approximately 2 million dual-eligible beneficiaries are estimated to have mental illness (Psychiatric News, July 20). Data on the first four months of the transition were reported in the May American Journal of Psychiatry, and data on the remainder of the year were announced at APA's 2007 annual meeting. The report concluded that access obstacles identified in the first four months of the transition continued throughout the rest of the year and in some cases worsened.

The APIRE study, which was based on responses from a nationwide sample of psychiatrists, was the first to compile clinically detailed, national data on the impact of drug-plan management practices under Part D on dual-eligible psychiatric patients' medication access, treatment compliance, and clinical outcomes.

The proposed legislation “supports a series of efforts by APA to study beneficiary access to psychiatric medications under Medicare and to protect the availability of these medications within the Medicare program,” Robinowitz said.

Insurer Actions Limited

The legislation would bar several insurer actions that the APIRE study found were widespread. These include use of utilization-management tools such as prior authorization and step therapy for medications within the six specified drug classes.

Moreover, the bill would require insurers to provide temporary coverage of medications within any of the six protected classes after the PDP has denied initial coverage. Temporary coverage would continue during the appeals process, or up to 60 days following notice of the denial-of-coverage decision. Additionally, beneficiaries could request an independent review to examine a denial of coverage for drugs within the six protected classes. Newly approved medications within the six protected classes must be covered within 30 days of Food and Drug Administration approval.

Supporters Optimistic About Passage

If the bill passes during this congressional session, the changes would be effective as of January 1, 2008.

The bill's chances for passage appear solid, according to supporters, because several influential Democrats have already signed on as cosponsors. Another bill (HR 3025) introduced by Doggett would eliminate copayments for about 1 million low-income, dual-eligible Part D beneficiaries and has been included in a Senate bipartisan compromise bill (S 1107) addressing the same issue.

The text of the bills can be accessed at<http://thomas.loc.gov> by searching on their respective bill numbers, HR 3061, HR 3025, and S 1107. ▪