Medicare Access for Patients Rx (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’s prescription drug coverage, Medicare Part D.
The Lupus Foundation of America founded MAPRx in 2005 after Part D was created by the passage of the Medicare Modernization Act. Prior to the launch and implementation of Part D in 2006, MAPRx brought the patient advocacy community together to ensure the program met the needs of their constituents and all Americans. MAPRx members represent every segment of Medicare beneficiaries and join together to advocate on their behalf and collaborate with national and state policymakers to ensure all beneficiaries have affordable access to the medications they need.
Since its inception, the Coalition has worked with Congress, the Centers for Medicare & Medicaid Services (CMS), the Medicare Payment Advisory Commission, and other relevant stakeholders to strengthen Part D and continue to improve the program. MAPRx activities include advocating for robust coverage and CMS oversight, hosting educational briefings for lawmakers on Capitol Hill, conducting trainings for staff working with Part D beneficiaries, and producing an annual open enrollment guide to help beneficiaries understand the benefit and pick the plan that best suits their needs.
MAPRx Principles
MAPRx is guided by the idea that every Medicare Part D beneficiary should have timely, affordable access to the medications they need to live a healthy life. To that end, MAPRx has established the following guiding principles for our coalition activities to strengthen and improve Part D:
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 the Part D 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;
- Pharmacy and therapeutics (P&T) committee membership, including robust consumer representation, as well as process and procedural requirements should ensure access to medically necessary medications. These requirements should include procedural safeguards and timely review of every newly Food and Drug Administration (FDA)-approved drug so that beneficiaries do not encounter barriers, such as potentially long and unnecessary delays, that hinder their access to medication therapies.
IV. Plans should be required to provide clarity and transparency on coverage and on beneficiaries’ out-of-pocket costs. A mix of co-payments and coinsurance can cause significant confusion, especially for individuals on multiple and/or expensive medications trying to navigate the system and compare plans. The ability to understand the benefits provided in a plan, along with coverage levels and out-of-pocket costs, is an important factor for consumers when deciding which plan best meets their needs.
V. Notice of non-coverage, appeals and exceptions processes 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. Plans should publicly report denial rates, overturn rates on appeal, and decision timeframes.
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.
- Prior authorization should be processed electronically and in a timely manner, with decisions that support continuity of care.
VII. Out-of-pocket costs should be affordable and predictable. The annual out-of-pocket cap and the Medicare Prescription Payment Plan (MPPP) should work as intended for beneficiaries, and cost-sharing should be based on the net price of a drug rather than its list price.
VIII. Beneficiaries should have meaningful plan choice, including stable access to standalone prescription drug plans (PDPs) and Low-Income Subsidy (LIS) benchmark plans, with continuity of care when plans exit the market or change their coverage.
IX. Implementation of the Inflation Reduction Act (IRA), including the Medicare Drug Price Negotiation Program, should be informed by the experiences of beneficiaries living with chronic diseases and disabilities and should ensure they can reliably obtain negotiated drugs at their pharmacy of choice.
The MAPRx Coalition is supported by grants from PhRMA, Pfizer, GlaxoSmithKline, AbbVie, Amgen, AstraZeneca, BIO, Bristol-Myers Squibb, Eli Lilly and Company, Genentech, Merck, Novo Nordisk, Otsuka, and Viatris.