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Medicare Plans for Poor Refuse to Pay for Some Common Drugs

Posted on: Tuesday, 31 January 2006, 09:01 CST

By Judith Graham

When Medicare's new drug program began this year, almost 2 million needy Americans were assigned to drug plans that excluded many commonly used medications, according to a government report.

The study issued Friday by the Office of the Inspector General of the U.S. Department of Health and Human Services found that nearly a third of impoverished citizens were enrolled in Medicare drug plans that declined to cover 15 percent or more of commonly used drugs.

The federal Centers for Medicare & Medicaid Services attacked the findings, calling the office's methodology flawed and its results unreliable.

"All Medicare drug plans have to cover all medically necessary treatments," said Gary Karr, the agency's director of media affairs. Even if a specific drug isn't covered by a plan, a therapeutically equivalent alternative must be available, he said. If needy consumers don't like the plan they are in, they can change every month, he noted.

At issue are about 6.2 million people nationally who had received their medications through Medicaid, a joint state and federal health program for the poor, before being automatically switched to Medicare's new drug program on Jan. 1.

Virtually all of these consumers were randomly assigned to private health insurers' drug plans by the government, in an effort to ensure they had medication coverage from Medicare at the beginning of the year.

They are among America's most vulnerable citizens: 38 percent have cognitive or mental impairments, and 33 percent are disabled, according to the inspector general's report. Nearly 75 percent have incomes of $10,000 or less a year; less than 50 percent are high school graduates.

They are especially ill-equipped to negotiate the complicated rules that characterize Medicare's new drug program, according to critics.

"These people are so poor, so frail and so dependent, they don't know what to do or where to turn when they show up at the drugstore and the pharmacist says, 'I can't fill that prescription,' " said Robert Hayes, president of the Medicare Rights Center in New York City.

Under many state Medicaid programs, these consumers had broader access to drugs than they do now.

"Our nation's most vulnerable, low-income citizens are actually worse off under the new Medicare drug benefit than they were under Medicaid," Sen. Jeff Bingaman, D-N.M., said.

On average, the inspector general found, drug plans are paying for 92 percent of the 178 medications most commonly prescribed for these needy seniors and disabled citizens.

But there is wide variation among plans, which has ended up helping some consumers while hurting others.

The report found that 18 percent of needy consumers were automatically enrolled in plans that paid for all of the most common medications, while 30 percent were assigned to plans that exclude 15 percent or more of these drugs from their formularies, or lists of covered drugs.

If a consumer happens to be taking one of the disallowed drugs, he or she can get a doctor to prescribe another medication in the same category, said Karr, the Medicare spokesman.

But that advice ignores the reality that many needy consumers do not have regular doctors, Hayes said.

Source: Buffalo News

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