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Medicare Part D: Complex Coverage

Doctors Delve Into Medicare Part D Plans and Find What's Needed -- More or Less

WebMD Health News

June 19, 2007 -- Having trouble figuring out Medicare Part D? You're in good company. Even doctors need help navigating Medicare's prescription formularies, a new study shows.

But the study also shows that if doctors dig deeply enough, they'll likely find at least one widely covered drug in Medicare's most commonly used prescription drug classes.

The study, published in The Journal of the American Medical Association, comes from five experts, including Chien-Wen Tseng, MD, MPH, of Honolulu's Pacific Research Health Institute.

Since everyone on Tseng's team has an MD or PhD degree, you might think they would sift through Medicare Part D plans in a jiffy. But their task was no cakewalk.

In fact, the researchers conclude that there ought to be an interactive tool telling doctors which drugs are widely covered by Medicare.

Medicare Part D

There are plenty of plans offering Medicare Part D prescription drug benefits, and each plan's formulary -- the list of covered drugs -- may be different.

"Many states have more than 50 Part D plans," write Tseng and colleagues. That's a lot of formularies to wade through, so Tseng's team focused on Medicare Part D formularies in California and Hawaii.

Why those two states? California ranks No. 1 among states for the number of Medicare beneficiaries and No. 4 for the most Medicare Part D plans. Hawaii is closer to the other end of those two lists.

The researchers didn't analyze all drugs covered by Medicare. Instead, they focused on eight classes of drugs for three common conditions: high blood pressure, cholesterol problems, and depression.

Specifically, the eight drug classes are:

  • ACE inhibitors for high blood pressure
  • ARBs (angiotensin II receptor blockers) for high blood pressure
  • Beta-blockers for high blood pressure
  • Calcium-channel blockers for high blood pressure
  • Loop diuretics for high blood pressure
  • Selective serotonin reuptake inhibitors (SSRIs) for depression
  • Statins for high cholesterol
  • Thiazide diuretics for high blood pressure

All in all, the researchers tracked 75 prescription drugs in the California and Hawaii formularies.

Medicare Drug Coverage

Tseng and colleagues counted the number of formularies with widely covered drugs in those eight drug classes.

They defined "widely covered" drugs as drugs covered by at least 90% of plan formularies and with co-payments of $35 or less.

The researchers trolled through 72 California plans and 43 Hawaii plans.

They write that the "formularies varied substantially; however, all but one treatment class [ARBs] had one or more widely covered drugs at low co-payments," with similar findings in California and Hawaii.

Widely covered drugs tended to be generic drugs, the study shows. But that doesn't mean that all generic drugs were widely covered or low in cost.

Call for Help

Formularies change over time, note Tseng and colleagues.

They write that "if this type of coverage information were made available in interactive fashion via a web site, personal digital assistant-based tool, or e-prescribing software, clinicians could use this knowledge" in selecting medications for Medicare patients.

That doesn't mean that widely covered drugs should automatically be used.

"Clearly," write the researchers, "there will be situations in which a noncovered or higher cost-sharing drug is the more appropriate clinical choice for individual patients."

They add that "the convenience of prescribing a widely covered drug should not take precedence over discussing with patients any greater clinical benefits from less well-covered or more expensive drugs."

  • Confused about Medicare Part D? Get help from Marisa Scala-Foley on WebMD’s Medicare and You message board.

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