About MAPRx

MAPRx is a coalition of patient, family caregiver and health professional organizations committed to safeguarding the well-being of patients with chronic diseases and disabilities who rely on Medicare Prescription Drug Coverage. MAPRx member organizations advocate on behalf of these beneficiaries and collaborate with national and state policymakers to ensure they have the access to the medication therapies they need and deserve.

The Principles

I. Plans should be required to have a robust formulary and provide coverage for a variety of medications in each drug class or category.

II. Coverage should be required for Medicare Part D’s six protected classes of drugs and any additional classes where restricted access to those drugs would have significant health consequences.

III. Oversight of a prescription drug benefit should include monitoring of:

Plan operations with an emphasis on key performance measures such as frequency and types of complaints, timeliness and resolution of appeals, completeness of enrollment information accessible to pharmacists, and availability of changes to drug pricing;

Formulary design to determine that appropriate access is afforded to physician prescribed treatments and to ensure that the formulary does not discriminate or discourage enrollment by certain beneficiaries;

Plans’ use of utilization management tools such as prior authorization, quantity limits and step therapy (where a lower cost drug is tried first before a higher cost drug may be used), should be required to meet best practice standards and appropriate treatment guidelines;

Quality measures should be meaningful to help beneficiaries make an informed drug plan choice and provide CMS necessary information in its oversight role. Measures should include customer service, access to needed drugs, appeal and denial rates, beneficiary protections and overall satisfaction; and,

Pharmacy and therapeutic (P&T) committee membership, including robust consumer representation, as well as process and procedural requirements should ensure access tomedically necessary medications. These requirements should include procedural safeguardsand timely review of every newly FDA-approved drug so that beneficiaries do not encounterbarriers, such as potentially long and unnecessary delays, that hinder their access tomedication therapies.

IV. Plans should be required to provide clarity and transparency on coverage and on consumer’s out-of-pocket costs. A mix of co-payments and coinsurance can cause significant confusionespecially for individuals on multiple and/or expensive medications trying to navigate the systemand compare plans. The ability to understand the benefits provided in a plan, along with coveragelevels and out-of-pocket costs is an important factor for consumers when making a determination ofwhich plan best meets their needs.

V. Notice of non-coverage, appeals and exceptions process should be simple and understandable.

Enrollees should be given timely notice of the reasons for the denial of drug coverage and their appeal rights, including the right to an expedited review. Regulatory oversight should ensure sufficient consistency in exceptions processes among all plans so that providers can assist beneficiaries in an efficient and effective manner.

VI. Rigorous oversight of medication utilization management tools (such as medication substitution, step therapy or quantity limits) is critical.

• Insurers should not be allowed to override a health care provider’s practice of medicine by forcing utilization of certain medications or therapies that may be inappropriate to the care of their patients.

• Plans should provide information and transparency about their utilization management tools, including notice of plan changes and the right to appeal.

• Plans should provide clear, relevant patient information on the use of utilization management tools prior to enrollment.

MAPRx Recommendations for Medicare Part D

MAPRx urges policymakers to learn from the experience with Medicare Part D – build on its successes and improve on its limitations. To that end, we encourage the use of the following principles to guide the design of prescription benefit programs. We also encourage policymakers to improve on the limitations of Part D.

  • Plans should be required to have a robust formulary and provide coverage for a variety of medications in each drug class or category.
  • Coverage should be required for Medicare Part D’s six protected classes of drugs and any additional classes where restricted access to those drugs would have significant health consequences.
  • Oversight of a prescription drug benefit should include monitoring of: plan operations, formulary design, plans’ use of utilization management tools, quality measures, and pharmacy and therapeutic (P&T) committees.
  • Plans should be required to provide clarity and transparency on coverage and on consumer’s out of-pocket costs.
  • Notice of non-coverage, appeals and exceptions process should be simple and understandable.
  • Rigorous oversight of medication utilization management tools (such as medication substitution, step therapy or quantity limits) is critical to patients’ timely access to prescription drugs.

Limitations of Medicare Part D

Medicare Part D is by no means perfect – key limitations prevent beneficiaries from taking full advantage of the benefits of prescription drug therapy. Policymakers should understand the limitations of Part D and not replicate them:

I. Prohibit gaps in coverage, as they result in beneficiaries modifying their drug use by stopping or reducing their use of certain medications. From 2006, when the Medicare Part D drug benefit took effect, to 2011, beneficiaries were required to pay 100 percent of their drug costs after their total drug spending exceeded an initial coverage limit until they qualified for catastrophic coverage. Researchers have found some beneficiaries discontinue their drug therapy during the coverage gap. Fortunately, the Affordable Care Act closes this coverage gap by 2020.

II. Avoid Onerous Cost-Shifting onto Beneficiaries. Many Medicare prescription drug plans have added to their formulary a “specialty tier” for high-cost medications. Unlike lower cost medications, for which beneficiaries usually pay a set co-pay amount, these medications are subject to significant coinsurance, meaning that beneficiaries must pay a percentage of the medication’s cost. For drugs in the specialty tiers, this amount can be anywhere from 25-33%, leaving patients to pay thousands of dollars out-of-pocket for cost prohibitive drugs and biologics used to treat cancer, multiple sclerosis, hemophilia, lupus, rheumatoid arthritis, and other conditions. For many beneficiaries, the result is that they are denied access to the most appropriate, useful medication due to the fact that it is financially out of reach. For those who can afford the drugs, they pay enormous sums out of pocket to maintain their health.

III. Curb the Use of Restrictive Medication Utilization Management. Many Part D plans now employ medication utilization management tools, such as prior authorization, medication substitution or quantity limits that restrict a beneficiary’s access to drugs. For example, a “fail first” policy requires that beneficiaries prescribed an expensive medication must first use a less expensive or plan preferred medication, experience that medication failure first before the plan will pay for the original prescription. These policies place unnecessary barriers to patients’ access to the medications recommended by their physicians. For many health conditions, such policies threaten patients’ lives, safety and medical stability.

IV. Improve program effectiveness, including access, for beneficiaries eligible for low-income subsidies. Medicare makes additional payments to plan on behalf of beneficiaries entitled tosubsidies due to low income and asset levels (often referred to as “LIS beneficiaries.”) The asset testis a particular barrier for many low-income beneficiaries who need help paying for coverage.Despite outreach efforts, not all eligible beneficiaries have enrolled. In addition, a large number ofbeneficiaries are required to change plans each year because the premium for their current plan nolonger falls below the low-income subsidy level. Changing plans can cause disruption to continuityof care.

V. Improve beneficiary education, decision-making and assistance for choosing the Part D plan best for them. Beneficiaries need to be well informed and compare options in order to make themarket work well. However, a June 2012 report from the National Bureau of Economic Researchfound that fewer than 10 percent of individuals enrolled in what would be for them the most cost effective Part D plan. More needs to be done to encourage beneficiaries to shop around and toprovide beneficiaries with the tools and support needed to make well-informed decisions. In its March 2012 Report, MedPAC states that only about 6 percent of beneficiaries switched plans voluntarily.