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Edison, NJ --- U.S. Rep. Frank Pallone, Jr. (D-NJ), a senior member of the House Energy and Commerce Subcommittee on Health, was joined at a press conference today by New Jersey doctors who are frustrated by the overwhelming administrative hurdles they must jump through before their patients have access to drugs they were already promised by their private drug plans.
Since the Medicare Prescription Drug Plan went into effect in January, Medicare beneficiaries have encountered hidden restrictions when they try to obtain prescription drugs through the Medicare drug plans. Even when a drug is listed as available through a plan, unexpected barriers have been used by the sponsors of drug plans to delay or deny access. These restrictions are forcing doctors to file appeals and other paperwork that are taking time away from patients.
Pallone said there are three principal provisions used by Medicare drug plans to restrict access to prescription drugs listed as part of a private drug plan. They are:
· "Prior authorization" requirements. These provisions require the senior or his or her doctor to apply to the plan sponsor for approval before the plan will cover a specific drug. Often, prior authorization requirements can involve significant documentation burdens.
· "Step Therapy" requirements. These provisions require the senior to use a variety of different drugs--and have these therapies fail--before the senior is allowed to obtain the drug of choice; and
· "Volume limits." Volume limits restrict the quantity or dosage of the drug that can be prescribed for a senior, regardless of whether the senior's doctor has determined greater quantities or dosages to be clinically necessary.
"These restrictions are placing our seniors in jeopardy," Pallone said. "Every day, doctors here in New Jersey work with their patients to determine the proper medication and dosage needed to help them live better lives. However, under the new Medicare Part D program, their treatment regimen is being questioned by private drug plans that are more interested in the bottom line."
The New Jersey congressman pointed to a report released earlier this year by the Democratic Special Investigations Division of the House Government Reform Committee. The report, Medicare Drug Plans: Restrictions on Access to Formulary Drugs, found that 97-percent of plans place either prior authorization or step therapy requirements on at least one of the 100 most popular drugs, with the average plan restricting access to over 10-percent of the popular drugs listed as part of its plan.
Pallone said Democrats want to take the Medicare Part D program in a new direction. The Democratic plan would scrap the existing private plans in favor of a plan within the Medicare program. The New Jersey congressman would like to see the new program operate similar to the government program that now exists for veterans through the U.S. Department of Veterans Affairs (VA).
While the VA has a list of drugs approved for use, it does not have an overly burdensome exceptions and appeals process that restricts access to drugs. According to a General Accountability Office (GAO) investigation completed in January 2001, "VA health care providers who prescribed drugs generally reported that veterans get the drugs they need. These prescribers reported that the national formulary generally contains the drugs their patients need, or, when necessary, prescribers can usually get nonformulary drugs." |
