Private Drug Plans Impede Older and Disabled Americans’ Ability to Get Prescriptions Filled

Private Drug Plans Impede Older and Disabled Americans’ Ability to Get Prescriptions Filled

People with Medicare are not getting the information they need from Part D drug plans to make an informed choice or to secure their rights once they have enrolled in a plan, according to a new report released by California Health Advocates and the Medicare Rights Center.

The report looks at critical consumer information provided by the six companies sponsoring drug plans in California that were assigned members who receive both Medicare and Medicaid. Most of these plans also provide drug coverage in other states.

“Why is it so difficult for people to get information about their own plan and coverage? Informing the customer comes last in this scenario,” commented Clare Smith, CEO of California Health Advocates, a Medicare advocacy organization.

In general, the authors found that the plans did not adequately explain the restrictions they impose on certain drugs, leaving potential enrollees uncertain whether or not the drugs would be covered for them.

With only one exception, these plans failed to publicize their transition policies, a failure that contributed to new enrollees being unable to fill prescriptions during January, the first month of the drug benefit.

The report also found that a lack of adequate information makes it difficult or impossible for people to appeal for coverage of drugs that the plan normally will not pay for. This failing in particular prompted the Centers for Medicare and Medicaid Services to extend mandatory transitional supplies of non-covered drugs from 30 to 90 days late last week.

“Plans that stonewall the appeals process must be penalized,” said Robert M. Hayes, president of the Medicare Rights Center, a national consumer service organization. “The Centers for Medicare and Medicaid Services should not be a lap dog regulator bowing to the insurance industry while people with Medicare leave the pharmacy empty handed.”

California Health Advocates and the Medicare Rights Center, co-authors of “The Knowledge Gap: Drug Plans Fail to Provide Critical Information to People with Medicare,” recommend that CMS:

  • Instruct plans to adequately explain the restrictions they impose on covering certain drugs and make readily available the procedures to obtain coverage;
  • Require that plans publicize policies that allow new enrollees a transitional supply of drugs that are not covered or are restricted;
  • Ensure plans make readily available procedures to appeal for coverage;
  • Sanction plans that fail to meet these requirements.

The Knowledge Gap: Drug Plans Fail to Provide Critical Information to People with Medicare is available online.

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California Health Advocates is a nonprofit organization dedicated to timely and responsive education and advocacy efforts on behalf of California Medicare beneficiaries and the pre-retirement population. For more information about CHA, call (916) 231-5110 or visit www.cahealthadvocates.org

Medicare Rights Center is the largest independent source of health care information and assistance in the United States for people with Medicare. For more information about MRC, call 212-204-6219, or visit the MRC web site:www.medicarerights.org.

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.