MEDICARE PART D: EARLY EXPERIENCES (PDF) | Behavioral Healthcare Executive Skip to content Skip to navigation


June 1, 2006
by root
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On January 1, the federal government launched the new Medicare prescription drug program (“Part D”) with much fanfare. Given the size of the new program, perhaps it's no surprise that there have been some bumps in the road. Some of the problems have involved beneficiaries eligible for both Medicare and Medicaid (“dual eligibles”), many of whom are consumers of mental health services. In the following pages, behavioral health thought leaders detail what has been working—and what has not—in the early months of Part D. Also included on page 48 is a handout for consumers and families about working with Medicare prescription drug plans; providers are invited to photocopy and distribute it to their clients.

We remind readers that the information in this special section is current as of press time.

A Mixed Bag for Consumers

Even die-hard patient advocates, such as Andrew Sperling, legislative director of the National Alliance on Mental Illness (NAMI), say that Medicare Part D, for the most part, has overcome a rocky start.

There were clearly problems in the transition into Part D. For example, when beneficiaries enrolled in prescription drug plans (PDPs), their data “didn’t catch up with them at pharmacy counters,” Sperling explains, which created enormous problems in getting immediate medication refills. Although “pockets of problems still exist,” that issue largely has been remedied, says Sperling.

But there still are vexing issues that have yet to be resolved. For example, Sperling notes, the “cumbersome” exceptions process is just starting to plague the program and beneficiaries. Until March 31, under the transition guidance, PDPs were required to refill prescriptions regardless of whether there was prior authorization, explains Sperling. As of April 1, if a particular prescription has not received prior authorization, a plan would have to make an exception for the patient’s clinical circumstances, he says. The difficult exceptions process—which often requires a multitude of forms to complete and comprehensive physician documentation, including furnishing peer-reviewed journal articles—will take months to play out, says Sperling. (Since this interview with Sperling, however, the American Medical Association and America’s Health Insurance Plans, in conjunction with the Centers for Medicare and Medicaid Services, have issued a standardized exceptions form for providers, which can be found at

Yet by and large there have been many positives to the program, notes Sperling. For example, the Oklahoma Medicaid program has a cap of six prescriptions per month. “But under Medicare Part D, if major plans, such as Coventry, Humana, and Anthem, offered an effort that capped prescriptions at a half-dozen a month, they would never get into the program,” he explains. “There can’t be a cap under Medicare.”

Another example: In Mississippi, the Medicaid program allows five prescriptions a month, only two of which can be brand-name drugs. “Dually eligible beneficiaries in Mississippi are substantially better off because there is no restriction on brand-name drugs under Medicare Part D,” he explains.

Sperling believes that many of the problems that still exist are endemic to the statute itself. For example, Part D excludes coverage of benzodiazepines. In addition, he says, dually eligible consumers sometimes are paying more than they did under Medicaid because PDPs and pharmacists have very limited authority to waive cost-sharing and copay provisions that exist under Medicare, but don’t under Medicaid. “This is a hardship for people who are living on $580 a month,” Sperling asserts, explaining that $580 is close to the average SSI or SSDI benefit for most dual eligibles.

Another statutory issue: Some low-income persons on fixed incomes but who have assets, such as savings accounts, do not quality for subsidies under Part D. “These people were supposed to be getting a subsidy—as much as $4,000 a year—to afford drug coverage, but because of the asset test, they can’t,” explains Sperling. “Many of these people simply aren’t going to sign up for the program because they can’t afford the monthly premiums on their own.”

Sperling also adds that enrollees face quantity and dosage limitations on prescription drugs.

To help ease the burden for both beneficiaries and their “support groups,” Sperling has earned scads of frequent flyer miles, making presentations in at least 37 states since the beginning of the year. NAMI has produced both printed and Web-based materials to educate patients and caregivers and has collaborated with other organizations, including the American Psychiatric Association and the National Mental Health Association through a Web site, www.mental “We have done a lot of outreach, but we have not done direct enrollment assistance,” he says. “I have, however, operated a dedicated e-mail system, where we’ve done direct casework and helped consumers with prescription drug issues, and we have a separate extension [(888) 999-6264, ext. 1228] that consumers can call to get answers to their questions. If we can’t answer them, we’ll contact the Centers for Medicare and Medicaid Services.”

The most important educational message to consumers is to emphasize the importance of plan choice, according to Sperling. “The choices should be based on a whole range of factors, including where the consumer lives and the medications he or she has been prescribed,” he explains.