Oppose Language from CMS That Will Restrict Access to Important Medications for People with Disabilities

2014-02-18 | , The Arc

Oppose Regulatory Language from CMS That Will Restrict Access to Important Medications for People with Developmental Disabilities Who Receive Medicaid and Medicare (the Dual Eligibles)

Background:

The Centers for Medicare and Medicaid Services (CMS) is proposing to revise the long standing policy that requires Medicare Part D prescription drug plans to include on their formularies (the list of drugs covered by the plan) “all or substantially all” drugs within six classes:

  • antidepressants (e.g., Prozac, Effexor, Zoloft) used for treating depression,
  • antipsychotics (e.g., Risperdal, Zyprexa, Seroquel) used for treating psychiatric disorders such as schizophrenia and bipolar disorder
  • anticonvulsants (e.g., Depakote, Tegretol, Lamictal) used for preventing or reducing seizures,
  • immunosuppressants used to prevent the rejection of transplants,
  • antiretrovirals used in the treatment of HIV and AIDS, and
  • antineoplastics used to treat cancers.  

This policy, known as the “six protected classes” policy, is an important consumer protection that has been in effect since the roll out of Part D.  People who are Medicare beneficiaries or are dually eligible for Medicare and Medicaid receive their prescription drug coverage through Medicare Part D.

Impact:

CMS is proposing that antidepressants and immunosuppresants lose protected status in 2015 and anti-psychotic medications in 2016.   This would likely mean that Medicare Part D prescription drug plans would not continue to cover all or substantially all of the drugs in these medication classes.  People who require medication not on the drug plan’s list would have to either: 

  1. pay out of pocket; 
  2. change to a potentially less effective medication or a medication that may have additional side effects; or
  3. utilize the exceptions or appeals process to try to gain access to the drug (with no assurance that this process would be successful).

Prescription medications  - particularly in the medication classes described in this Action Alert -  are not interchangeable, and doctors prescribe treatments to meet the unique needs of each person.  When the Medicare Part D program was initiated, these classes of drugs were protected because of concerns that Part D formularies would be restrictive and limit access to medications.   CMS is proposing these changes to save money.  However, it is highly likely that disrupting access to needed medications will be a threat to the person’s health and well-being and may lead to increased Medicare expenditures by resulting in more doctor visits, hospital emergency room visits, and hospitalizations.

What You Can Do:  

Advocates and families must write to CMS and urge them to drop the language making changes to the antidepressant, antipsychotic, and immunosuppressant medication classes.  Comments are due no later than March  7th.  To provide comments electronically:

  • Go to www.regulations.gov and in the search box enter RIN 0938-AR37
  • Click the “comment now” button next to the regulation called “Medicare Program:  Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs.” 

Or written letters, which must be received by March 7th, can be sent to:

Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention:  CMS-4159-P
P.O. Box 8013
Baltimore MD 21244

 

Sample Letter/Electronic comment:
Marilyn B. Tavenner
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention:  CMS-4159-P
P.O. Box 8013
Baltimore MD 21244

Dear Administrator Tavenner,

The Arc of the United States is very concerned that the Centers for Medicare and Medicaid Services (CMS) is proposing to dismantle the six protected classes of medications in the Medicare Part D prescription drug program.  Restricting access to needed medications in the interest of saving money is harmful to Medicare beneficiaries and people who are dually eligible for Medicare and Medicaid.  The Arc urges CMS to keep the six protected classes and maintain this important beneficiary protection as it exists today.

The Arc is concerned that people with I/DD who are eligible for Medicare or dually eligible for Medicare and Medicaid will be hurt by this policy.  Some people with I/DD may also have depression or other psychiatric disorders that require access to the specific medication that works for the individual or causes fewer side effects.   Often people have complex medical conditions that must be managed.  Frequently, they have tried less expensive, generic drugs that simply have not worked.  Many of these individuals would have difficulty navigating the complicated exceptions process or filing an appeal and very few could manage paying for these drugs out of pocket. 

The Arc believes it is a critical beneficiary protection to ensure that Medicare prescription drug plans provide all or substantially all of the drugs in the six protected classes.  Prescription medications are not interchangeable for every person and doctors must be able to prescribe treatments to meet the unique needs of each person.  The Arc urges CMS to remove these harmful provisions from the proposed rule and maintain the current beneficiary protections.  Thank you for considering our comments.