Medicare Drug Benefit Covers Fewer Medications Than Medi-Cal
Many low-income Californians enrolled in the Medicare drug benefit have coverage for fewer medications than they did under Medi-Cal, according to a study released on Tuesday by the California HealthCare Foundation, the Los Angeles Times reports. Drug coverage for dual eligibles -- beneficiaries eligible for both Medicare and Medicaid -- was transferred from state Medicaid programs to Medicare when the drug benefit took effect Jan. 1.
The study, which was conducted for CHCF by Avalere Health, is "among the first assessments" of Medicare drug coverage that is "based on government data rather than anecdotal evidence," the Times reports.
The study said that the most restrictive drug plan that accepts dual eligibles in California covers 626 medications and that the most inclusive plan covers 3,360 medications. By comparison, Medi-Cal covered "virtually all" 8,000 medications approved by FDA, according to the Times.
Medicare drug plans are required to cover at least two treatments in every major medication class (Alonso-Zaldivar, Los Angeles Times, 3/21).
In addition, the study found that dual eligibles must pay higher copays under the drug benefit than under Medi-Cal, which charged nonmandatory copays of $1. Medicare drug plans typically charge copays of $1 to $5, the study said.
The study examined coverage for four categories of drugs:
- Antipsychotics, which are used to treat psychotic conditions such as schizophrenia;
- Antiretrovirals, which are used to treat HIV; and
- Antihypertensives and anticholesterol drugs, which are both used to treat high blood pressure and cholesterol.
Medi-Cal covers 20 antipsychotic medications, compared with a median of 18 medications for Medicare PDPs, according to the study. In addition, Medi-Cal covers 23 antiretrovirals, the same median as Medicare plans.
Medi-Cal covers 12 blood pressure drugs and 14 cholesterol-lowering drugs, compared with a median of eight antihypertensives and 10 anticholesterol treatments. According to the study, "Many ... beneficiaries, even if they are properly enrolled in a drug plan, have coverage that is inferior to their coverage under Medi-Cal for the four classes analyzed" (Los Angeles Times, 3/21).
The study also examines coverage under stand-alone prescription drug plans, Medicare Advantage plans and special needs plans. It looks at coverage of the 100 most commonly prescribed drugs under 10 different plans. The study finds:
- Five of the 10 plans offer "high drug coverage," which the study designates as coverage of more than 95 of the top 100 drugs for PDPs and more than 90 drugs for MA plans;
- Two of the 10 plans offer coverage during the so-called "doughnut hole," or gap in coverage for which beneficiaries are responsible for 100% of annual drug costs between $2,250 and $5,100;
- Three of the 10 plans have no deductible;
- All 10 plans cover at least 88% of the 59 commonly prescribed medications that are available as generics; and
- Most plans restrict coverage of brand-name drugs through use of prior authorization, generic substitution or other requirements ("The Medicare Drug Benefit: How Good Are the Options?" March 2006).
According to the Times, the "findings could have national implications, as federal and state lawmakers grapple with ways to work out problems with the new benefit."
Jonathan Blum, a vice president at Avalere Health, said the findings are "true across the county -- this is not a California phenomenon."
CMS Administrator Mark McClellan said some of the brand-name drugs that are not covered under some plans have generic equivalents that are covered by the plans (Los Angeles Times, 3/21).
The complete report is available online. Note: You must have Adobe Reader to view the report.