Add a Drug Coverage Option to the Original Medicare Program

People with Medicare need a drug benefit that covers the drugs they need at prices they can afford. The Medicare Part D program does neither.

The Part D program relies on insurance companies to hold down costs by barring or restricting coverage for certain drugs in the plans they offer. Prices are higher than those the Veterans Administration is able to negotiate. In fact, although Medicare pays 75 per cent of the cost of coverage through Part D plans, the expense to the consumer is comparable to, and often higher than, what they would pay if they were to buy drugs from Canada, without any government subsidy at all.

Lowering drug costs is one of the Medicare Rights Center’s main priorities. We’re working hard to allow Medicare to negotiate lower drug prices and administer prescription coverage directly instead of through private insurance companies.

“It takes us time to go to Canada, but it’s worth the trip,” say Mr. and Mrs. Q of Maine.
For over three years, the couple has been regularly crossing the border to buy prescription drugs. Both have diabetes and high blood pressure, and Mrs. Q has high cholesterol. Buying Canadian-priced drugs for their conditions saves the couple $2,655 a year!

If Medicare were to administer the drug benefit and negotiate better prices as other industrialized countries like Canada do, there would be enough savings to close the “doughnut hole” or gap in Part D coverage, when people continue paying premiums but pay the entire cost of their drugs.

Many people with Medicare have also experienced problems obtaining coverage for drugs that treat mental illnesses. Medicare Part D plans impose a range of restrictions on mental health drugs that result in the denial of coverage.

Requirements to obtain prior authorization and excessive cost-sharing often block access to antipsychotics and antidepressants—medications that treat serious mental illnesses. The benzodiazepines, medicines used to treat anxiety and panic disorders, insomnia and related conditions, are completely excluded from Part D coverage.

Ms. Z is 64 years old and has suffered from schizophrenia for over thirty years. She takes Abilify and Zyprexa to control her symptoms. Before January 1, 2006, these drugs were covered by Medicaid.

For five years, Ms. Z’s medications helped stablize her condition. But in January 2006, Medicare Part D went into effect. People like Ms. Z, who had both Medicare and Medicaid, were transferred to a Medicare private drug plan for coverage of their medications. Ms. Z. was automatically enrolled in a randomly assigned plan.

When she attempted to fill her prescriptions using her new drug plan, the pharmacist told her that her medications required prior authorization.

Ms. Z left the pharmacy empty-handed and confused. The pharmacist had not explained what prior authorization was, nor did he use her plan’s transition policy to fill her prescriptions.

Ms. Z. then turned to a caseworker at the medical clinic where she receives her regular care. She was told that only the doctor could give prior authorization, and because he only came to the clinic twice a week, and saw over 50 patients a day, it would be virtually impossible for him to find the time to secure the necessary authorization.

People with Medicare are feeling the impact of the decision by Congress to hand the drug benefit to private insurance companies instead of administering it through the Medicare program. Older adults and people with disabilities are finding that their medications are not covered and they’re facing obstacles when they appeal for coverage. Many people are experiencing more restrictions and paying higher co-payments than they did with the coverage they had prior to the implementation of Part D.

The Part D program is a bad deal for people with Medicare and for all taxpayers!

The Medicare Rights Center supports a number of legislative and regulatory changes that will help people with Medicare get the drugs they need. We’re working to:

Make it easier for low-income people with Medicare to receive Extra Help under the Part D benefit, including elimination of the asset test for the Extra Help program.
Protect people with Medicare from deceptive marketing by Part D and Medicare private health plans and ensuring that no one is “locked in” a plan that does not meet their needs;
Make the Part D appeals system work fairly and efficiently;
Ensure unrestricted access to all medically necessary mental health drugs and other critical medicines.

As a concerned citizen, you can act for change in Congress. Take action now!

The Medicare Rights Center publishes many talking points about and reports on the Drug Benefit:

Add a Drug Coverage Option to the Original Medicare Program

Resources for Understanding and Talking About Fixing the Medicare Drug Benefit

Reports:

Testimony:

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