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Medicare Drug Plans Are Onerous and Restrictive

Doctors and pharmacists face a lot of problem due to the new Medicare drug plan. Each plan has its own list of covered drugs, known as a formulary. // These plans require the patients to obtain prior authorization from the doctors. One plan may have 25 or 30 forms for prior authorization for different drugs. Most states have at least 40 Medicare drug plans.

Doctors say that these Medicare plans make the system complicated and delay the access of the medication. On the other hand the insurers say the requirements save money and promote the proper use of the medications. Dr. Jeffery A. Kerr said that these plans have created significant hurdles that patients and physicians must jump over before getting their medications. Dr. Kerr said the Medicare plans were more noticeable because Medicare beneficiaries are high users of prescription drugs.

Dr. Steven A. Levenson of Towson, Md., president-elect of the American Medical Directors Association said that the Medicare drug plans with the help of the management prevent the access to medically appropriate drugs, including drugs on the patient’s own formularies. The pharmacists also face a lot of problems as they have to request prior authorizations for hundreds of drugs taken by Medicare patients, which have its own policies, forms and procedures.

President Bush said that these plans benefit a number of senior citizens. He also said that those who enroll in this plan will end up spending only about half of what they used to spend on prescription drugs each year. He said that these problems will soon be cleared.

Francis S. Soistman Jr., executive vice president of Coventry Health Care, said that he was not aware about the number of forms the doctors have to fill in before prior authorization.

His company's Web site has 39 forms for doctors to use when prescribing certain drugs for Coventry Medicare plans, marketed under the name AdvantraRx. At the top of each form is a logo saying AdvantraRx: Medicare prescription drug plans made easy. But then he said that each drug has a unique clinical criterion that must be met. Hence these forms serve as a checklist of necessary information which is needed for the company’s review. He also said that prior authorization limits the use of certain drugs like OxyContin and Accutane. In addition, this would prevent the overuse of high-cost medications and to ensure that equally effective, less expensive agents are used first.

The prior authorization forms requires the doctors to provide details of laboratory test results, all office notes and other data to show why certain drugs are needed.

But Dr. Lyons said that it would be desirable to simplify and standardize the prior authorization process.

Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services said that the program was working smoothly for the vast majority of the beneficiaries and that he would look into all the other problems. He also said that there were improvements on a daily basis.

Officials reported that the health plans have been encouraging and the growth of prescription drug spending slowed to 8.2 % in 2004, after nine years of double-digit increases.

John Feather, executive director of the American Society of Consultant Pharmacists said that the use of prior authorization is far more prevalent in Medicare than in commercial insurance programs. Dr. Charles A. Crecelius, a geriatrician in St. Louis, said that the drug plans say they cover more than 90 of the 100 drugs but did not do so. This is due to the reason that the drug may be on the formulary but difficult to obtain because of the prior authorization and other rules.


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