Medicare Part D drug plan, getting the right drugs 2/06

In this report: Overview; HMO or traditional Medicare?; The 3 flavors available; Getting the right drugs; Should you join?; One senior's search for a good plan

February 2006

Getting the right drugs

Each plan has its own distinct formulary, or list of covered drugs. After you enter the names of the drugs you take in the Medicare Web site's search tool (at www.medicare.gov), it will produce a list of plans that include them in their formularies.

Drugs can go on and off the formularies at any time, and it's possible that a plan will not cover every drug you take, forcing you to pay for the medications out of pocket (an expense that doesn't count toward meeting the deductible or filling the doughnut hole). Your plan must notify you when a drug goes off its formulary and provide a transition plan that will allow your doctor 60 days to file for an exception or to change your treatment plan.

There's yet another wrinkle. The insurer may impose restrictions on certain medications. Many insurers require you or your doctor to get their approval--or preauthorization--before they will pay for certain drugs, ones that are likely to be taken incorrectly or prescribed inappropriately. If the plan covers the drug, copayments for the appropriate tier will apply. If it doesn't, you pay.

Companies also target certain medications, such as pain relievers, for "step therapy." Before it will cover a drug, the plan asks you to try a therapeutically equivalent and less expensive drug. If it doesn't work, the plan steps you up to the next least expensive drug in the class. The plan keeps stepping you up until you and your doctor find a drug that works.

Companies use such restrictions to manage the cost of the drug benefit and encourage patients to use generics, not an unreasonable strategy. But you'll have to be persistent to get this information. Pacificare, for example, uses more of those management tools for patients who choose its lowest-cost plans, but its information brochure simply points out that the company may offer "medication therapy management." Unless you take only the least expensive, generic drugs, you'll have to ask plans you're considering whether your medications are subject to preauthorization or step planning.

That's just one more hurdle in what's likely to be a rather arduous shopping effort for most seniors. Many are likely to throw up their hands in exasperation and avoid enrolling altogether. That would be a shame, since the new drug benefit offers many consumers true savings. At this point, however, they come with too much confusion.