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Medicare Drug Coverage Doesn't Assure Easy Access to Medications

SUNNYVALE, Calif., Aug. 8, 2013 /PRNewswire-USNewswire/ -- A new analysis from HealthPocket of Medicare drug plans reveals that in both traditional Medicare and Medicare Advantage plans, consumers face various hurdles in accessing their medications. In assessing the highest number of drugs covered with the fewest barriers to getting them, wide variations were seen among plans, with some having more than twice the number of drugs covered as others. On average, 16 percent of drugs within a plan had limitations on the quantity allowed to be purchased at one time; 18 percent of drugs required the health care provider to contact the plan to get prior authorization; and nearly 2 percent required "step therapy" where a less expensive medication must be tried first.   

An estimated 90 percent of Medicare enrollees have some form of drug benefit, affecting about 45 million Americans. As is true in the private health insurance market, each Medicare plan has a "formulary" that lists out which drugs are covered and what out-of- pocket costs a consumer is responsible for in a given year for those medications. If a consumer is on a drug that does not appear on the plan formulary, he or she will have to pay the full cost. Yet even if a drug is on the formulary, plans can restrict access to it through various mechanisms, including limiting the quantity; requiring prior authorization; and mandating a step therapy process for certain medications.

"Annual enrollment is coming up in October, and that's when consumers have an opportunity to compare health plans on important factors, including drug coverage," said Steve Zaleznick, executive director for Consumer Strategy and Development at HealthPocket. "The first step for Medicare enrollees and all consumers is to ensure that the drugs they take are on the plan's formulary, and the second is to look at what restrictions they may face in actually getting the medication in hand."

While many plans engage in these cost-cutting measures, Kaiser plans had no quantity limits, no step therapy rules and only 3.5 percent of its drugs were subject to prior authorization. As new and reformed Medicare and private plans come online through the Affordable Care Act, this model may prove useful to industry and government alike as the health care system seeks to improve quality, save costs and provide positive consumer experiences.

This HealthPocket InfoStat is part of a series using health plan data to produce unbiased market analysis and guidance for consumers navigating America's changing health insurance environment. More information about out-of-pocket costs and Medicare plans can be found at   

About HealthPocket is a free website that compares and ranks all health plans available to an individual, family, or small business, so everyone can make their best health plan decision and save on their out-of-pocket costs. The Company uses only objective data from government, nonprofit, and private sources that carry no conditions that might restrict the site from serving as an unbiased resource. The founders of spent decades pioneering online access to health insurance information and knew they could offer something different that can positively change how people buy and use healthcare in the U.S. Learn more at

SOURCE HealthPocket
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