Medicare Drug Benefit

The Medicare drug benefit's structure creates incentives for prescription drug plan providers to limit coverage of expensive or frequently used medications, including treatments for mental illnesses, according to a paper in the May/June issue of Health Affairs. Coverage policies for psychotropic medications under the Medicare drug benefit could have notable implications for beneficiaries with mental illnesses because of the extent to which treatment of mental illnesses in Medicare beneficiaries relies on the use of these medications.

The author suggests that some coverage guidelines used to assess medications for other types of illness might not be well-suited to medication management of psychotropic drugs. For example, the abrupt discontinuation of some mental health medications could result in severe side effects, making prior authorization, step therapy or quantity-limiting requirements unsuitable for beneficiaries with mental illnesses.

To counteract the effects of the incentives to limit coverage, the author suggests that CMS:

• Assess risk sharing and adjustment in various plans to allow for the coverage of expensive medications;
  
  
• Change formulary rules so that plans cover wider selections of drugs in various drug classifications; and
  
  
• Supervise plans to make sure they are using all available management tools.