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January 17, 2014
By Diane C. Lade, Staff writer
Proposed changes would affect coverage for antidepressants such as Prozac,… (Darren Staples/Reuters…)
The Centers for Medicare & Medicaid Services (CMS) has announced rule reforms for drug coverage under the HMO-style Medicare Advantage health-care plans and stand-alone prescription plans issued by private insurers.
These proposals include removing antidepressants as well as immunosuppressants from the current six classes of “protected” drugs that receive special oversight (because they are considered vital to seniors’ health). Doing so would mean any private Medicare plan offering a Part D drug benefit, either through a health-care plan or prescription-only policy, would no longer be required to cover all of those types of medications on the market.
CMS officials said the changes were designed to “improve health care quality, reduce costs for Medicare beneficiaries … and combat fraud, waste and abuse.”
The agency is changing the criteria for protected drugs to include only those where patients would die, be disabled or hospitalized if they went without the medications for seven days, which CMS says doesn’t include antidepressants or immunosuppressants (primarily used for organ transplant recipients, or those with autoimmune diseases like lupus). Plans will have more freedom to negotiate better prices for their customers, CMS officials said, if they aren’t required to carry all the drugs in a class.
If approved, changes would go into effect for the 2015 plan year. CMS, which gained the authority under the Affordable Care Act to make the rules regarding protected medications, is gathering public comments on the proposals through March 7.
Any tinkering with private Medicare plan rules especially affects Florida, which has a high percentage of seniors enrolled in them and more plans to choose from than almost anywhere else in the country. There were 81 Medicare Advantage plans offered in Broward County and 67 in Palm Beach County for 2014.
“Proposed changes to protected classes are a rollback on consumer protections, no way around it. We are hoping that CMS will get a flood of comments and back off,” said David Lipschutz, policy attorney for the Center for Medicare Advocacy in Washington, D.C.
But while advocates are circling the wagons to fight protection modifications, they said some of the 2015 change proposals could benefit consumers. Among them: Limiting insurers to two stand-alone drug plans offerings — one basic policy and one enhanced policy — in each market, which would make it easier for consumers to shop for coverage.
Another proposal would allow more network pharmacies to be preferred providers, which are the retailers with the lowest drug prices.
“This should enable patients to go to a wider network and get lower prices,” said Juliette Cubanski, an associate director at the Kaiser Family Foundation, a health-care policy analysis nonprofit.
Depression is a serious and widespread problem among seniors, often overlooked but now gaining attention. About 6 million of the 40 million Americans older than 65 suffer from depression, according to the Geriatric Mental Health Foundation, a nonprofit dedicated to raising awareness about late-in-life mental illness.