Part D is designed to encourage competition among its approved benefit plans in order to foster cost-effectiveness, and so far this outcome is being met. However, the burden of sorting through all of the choices and selecting the best plan for an individual’s needs falls on the patient—and secondarily upon the doctor who must provide optimal medical care within the limits of the chosen plan.
Not only does the clinician need to work with a formulary of pre-approved drugs, but he or she must also consider the cost-sharing requirements for the given drugs. For example, the most common cost-sharing arrangement is a three-tier system of co-payments: the lowest co-pay for generics (tier 1), a higher co-pay for preferred brands (tier 2), and the highest co-pay for non-preferred brands (tier 3).
However, many plans use a “specialty tier” for biologic or injectable drugs—some of which are successfully used to treat RA. While the CMS guidelines recommend charging beneficiaries no more than 25% of the cost of these specialty tier drugs, several plans impose a specialty tier charge between 30% and 33%.
Jack Hoadley, PhD, a research professor at the Health Policy Institute of Georgetown University in Washington, D.C., has completed an in-depth study of formularies and Medicare plans. He includes a detailed explanation and table of the TNF inhibitors in his paper, “An In-depth Examination of Formularies and Other Features of Medicare Drug Plans.”2
“Fourteen of the plans studied offered different levels of coverage so they have the flexibility to make things more or less expensive,” says Dr. Hoadley. “As one analyst put it, this plan is like a roller coaster—up and down and starting over every year.”
Further, utilization management tools—prior authorization, quantity limits, and step therapy—can also have a negative effect on drug costs for rheumatology patients. Again, in an effort to contain costs, some plans impose quantity limits and step-therapy programs (requiring patients to take a less expensive drug before receiving a more expensive alternative). These cost-containment efforts impose yet another restriction on the prescribing rheumatologist.
Prior Authorizations
By far the frustration most often mentioned by the rheumatologists seems to be the need for prior authorization to use a drug not on a plan’s formulary. Some of these problems exist because of confusion between coverage from Medicare Part B and Medicare Part D. For example, a prescription may be refused under Part D because it is an injectable or infusion or administered by a physician and therefore should be covered under Medicare Part B.
Patients should get what they need with less hassle factor.
–Gerald Eisenberg, MD
