Part D Plan Selection Poses Challenge for Patients

New trends in Medicare prescription drug plans will make this year’s selection process more difficult for patients to navigate.

Selecting a Medicare drug plan always involves planning and research, but experts say patients should be extra cautious this year. In their analysis of stand-alone Part D prescription drug plans, the research firm Avalere Health found wide variation in costs, copays, and drug formularies for 2011.

The inconsistencies could pose challenges for many seniors, who are more likely to take multiple drugs. Pharmacists can make the selection process simpler by ensuring patients have all the resources necessary to make an informed decision.

“This new analysis shows that consumers should put great thought into what drugs they are likely to need covered under their Medicare drug benefits before choosing a plan,” said Dan Mendelson, chief executive officer of Avalere health.

The following factors will affect the price and accessibility of coverage in 2011:

Cost structures. Many health plans are adopting 5-tier systems for formularies, enabling them to exact greater control over drug pricing. In 2011, 41% of all plans will have 5 or more tiers—an increase of 27% since 2009. Of those that are split into 5 tiers, 42% will segment generic drugs into 2 tiers, offering competitive pricing for preferred generics. In 27% of those plans, specialty drugs also will be subject to the 2-tier treatment.

Preferred pharmacies. Plans will rely heavily on in-network pharmacies to offer bargains on formulary drugs in 2011. Patients seeking the lowest out-of-pocket costs may be forced to switch pharmacies, depending on which plan they choose. Mendelson said patients’ costs could be “significantly higher if they don’t shop at the pharmacy designated by the plan.”

Prior authorization. Controls on drug utilization are expected to increase, with more plans imposing prior authorization requirements and quantity limits. The number of drugs subject to prior authorization will increase from 12.4% in 2008 to 16.7% in 2011. “Consumers need to be aware of these restrictions and know that appeals are available,” the report stated.

To avoid buyer’s remorse in 2011, patients should thoroughly review their medications and find a plan that best meets their individual needs, Avalere’s analysts said. Medicare.gov offers comparative tools that can help seniors size up plans based on their individual medication history and preferred pharmacy. For a step-by-step guide to using the tools, seniors can visit the AARP Web site.

“With major differences in cost sharing, deductibles, which drugs are on formulary, and tier placement of products, the optimal plan for a consumer will depend on which drugs they need within each category,” the report concluded.

For other articles in this issue, see:

• Seniors Taking Antidepressants at Risk for Drug Interactions
• Fair Pharmacy Reimbursement a Result of Health Reform
• Grant Targets Dwindling Options for Pharmacy Grads