Prior Authorization Requirements of Medicare Drug Benefit Examined

The New York Times on Tuesday examined how some physicians and pharmacists maintain that many medications covered by Medicare prescription drug plans are "not readily available" to beneficiaries because of prior authorization requirements. Medicare prescription drug plans require prior authorization -- or preapproval from the plan sponsors -- as a prerequisite for coverage of many medications.

Medicare prescription drug plan sponsors maintain that prior authorization requirements prevent unnecessary prescriptions and encourage the use of less-expensive medications. However, some physicians and pharmacists maintain that prior authorization requirements used by Medicare prescription drug plans are excessive and could prevent access to some medications for beneficiaries.

According to the Times, a Medicare prescription drug plan might have "25 or 30 forms" for prior authorization for different medications. The forms often require laboratory test results, "all office notes" and other data to demonstrate need for medications, the Times reports.

Steven Levenson, president-elect of the American Medical Directors Association, said, "We have seen signs that Medicare drug plans are using management controls to deter access to medically appropriate drugs, including drugs on their own formularies."

David Bernauer, chair of Walgreen, said, "It is impossible for pharmacists to keep track of all these formularies" and prior authorization requirements. Bernauer said that the federal government "should use its leverage to promote greater standardization of policies and procedures."

Francis Soistman, executive vice president of Coventry Health Care, said that prior authorization forms are necessary because "each drug requiring prior authorization has unique clinical criteria that must be met." In addition, he said, prior authorization forms "serve as a checklist of necessary information needed for our review." Soistman said that prior authorization requirements reduce the use of medications with potential for abuse; limit safety problems; prevent overuse of expensive medications; and help ensure that "equally effective, less expensive agents are used first."

Daniel Lyons, senior vice president of Independence Blue Cross, said that he supports efforts to "simplify and standardize the prior authorization process."

Babette Edgar, a former CMS official, said that agency officials analyzed the prior authorization requirements of Medicare prescription drug plans when they approved formularies for the plans last year (Pear, New York Times, 2/14).

In other Medicare news, HHS Secretary Mike Leavitt on Monday said that the percentage of dual eligibles who continue to experience problems with the prescription drug benefit has decreased from about 10% to between 3% and 5%, CQ HealthBeat reports. Many dual eligibles --- beneficiaries who are eligible for both Medicare and Medicaid -- have experienced problems with access to medications under the prescription drug benefit because of incorrect enrollment information in computer databases and other issues.

Leavitt said that problems with the Medicare prescription drug benefit are "still too heavy on the duals" and that the issues are "the kind of thing you go through when you implement a large systems change." He added, "We will not quit worrying about this until every Part D participant has connected with their plan. Once people have connected with their plan, things go smoothly."

Leavitt said that a proposed extension of the May 15 deadline for enrollment in the Medicare prescription drug benefit without penalty "is a policy decision that Congress will have to make," adding that "the value of a deadline is people get busy and take care of it." He said, "The good news is millions of people have drug coverage today who did not (before). We make no excuses here. The system gets better every day, and it will continue to" (Carey, CQ HealthBeat, 2/13).

The AP/Long Island Newsday on Tuesday examined how the experience that Medicare beneficiaries have with the prescription drug benefit could affect how they vote in midterm elections this fall. In the 2004 presidential election, voters ages 65 and older supported President Bush over Sen. John Kerry (D-Mass.) by a 52% to 47% margin.

In the 2004 House races, 51% of voters ages 65 and older voted for Republican candidates, compared with 45% who voted for Democratic candidates. Pollsters maintain that the opinions of Medicare beneficiaries on how lawmakers and the Bush administration respond to problems with the prescription drug benefit could affect their votes in the midterm elections (Freking, AP/Long Island Newsday, 2/14).

Summaries of broadcast coverage addressing the drug benefit appear below.

• KPBS' "KPBS News": The segment includes comments from Torrance pharmacy owner John Curtis (O'Mara, "KPBS News," KPBS, 2/13). The complete segment is available online in RealPlayer.
  
  
• KQED's "California Report": The segment includes comments from Medi-Cal director Stan Rosenstein (Erlich, "California Report," KQED, 2/13). The complete program is available online in RealPlayer.