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Some Drugs Covered By New Medicare Plan Are Not Available, Doctors Say

By Robert Pear


Doctors and pharmacists say many drugs theoretically covered by the new Medicare drug benefit are not readily available because of insurers’ restrictions and requirements.

The benefit is administered by scores of companies under contract to Medicare. Each plan has its own list of covered drugs, known as a formulary. Drug plans require doctors and patients to obtain “prior authorization” for certain drugs on their formularies.

The procedures vary from plan to plan. 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 the diverse requirements are onerous and can delay or deny access to needed medications. But insurers say the requirements save money and promote the proper use of the medications.

Dr. Jeffery A. Kerr, who cares for hundreds of older patients in southern Missouri, said: “Medicare drug plans have created significant hurdles that patients and physicians must jump over before getting their medications. The prescription drug plans are playing a dangerous game. In many cases, we’re dealing with frail, very vulnerable individuals.”

For years, commercial insurers and their pharmacy benefit managers have used similar techniques. But Kerr said the techniques used by some Medicare plans were more onerous and restrictive. They are also 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, which represents doctors who care for nursing home residents, said, “We have seen signs that Medicare drug plans are using management controls to deter access to medically appropriate drugs, including drugs on their own formularies.”

Ross W. Brickley, a pharmacist in Kinston, N.C., said he had requested prior authorizations for hundreds of drugs taken by Medicare patients in more than 20 plans, each with its own policies, forms and procedures.

“We have a world of chaos,” Brickley said.

David W. Bernauer, chairman of Walgreen, one of the biggest drugstore chains, echoed that concern.

“It is impossible for pharmacists to keep track of all these formularies” and prior authorizations, Bernauer said. The government, he added, “should use its leverage to promote greater standardization of policies and procedures.”

In his radio address on Saturday, President Bush described the drug benefit as “a good deal for seniors.” Those who enroll “will end up spending about half of what they used to spend on prescription drugs each year,” Bush said.

Yet, he acknowledged that problems had occurred.

“Some people had trouble the first time they went to the pharmacy after enrolling,” Bush said. “Information for some beneficiaries was not transferred smoothly between Medicare, drug plans and the states. And in the early days of the drug coverage, waiting times were far too long.”