Medicare Compliance & Reimbursement

Consumer group sees gap coverage for only generics as useless to seniors.

After the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) released data on what the private Medicare Part D drug plans will offer to enrollees in 2007, one consumer group is crying foul.

HHS Secretary Michael Leavitt claimed that Part D prescription drug plans (PDPs) would offer more options for beneficiaries to obtain gap coverage ...quot; coverage for drugs in the infamous Part D "doughnut hole."

But a Nov. 1 Families USA report refutes Leavitt's statement, claiming that the stand-alone PDPs offering gap coverage in 2007 offer coverage for only generic drugs.

"For doughnut hole coverage to be meaningful, however, it needs to cover the drugs that seniors actually use," the report says, going on to explain that 18 of the 25 most commonly prescribed drugs for seniors don't have generic forms.

"Drug plan coverage in the doughnut hole will be much scarcer in 2007, and, in those states where such coverage continues to be available, it will be far more expensive," Ron Pollack, Families USA's Executive Director, said in a Nov. 1 statement that accompanied the report. "This coverage gap never made sense, and now it is getting worse for seniors who take multiple prescription drugs."

But the New York City-based Center for Medicine in the Public Interest (CMPI) is calling Families USA's statement that fewer Part D plans are offering meaningful gap coverage "outrageous." To make that statement, "Families USA has twisted the definition of 'meaningful coverage' so that it refers only to coverage of brand-name drugs," according to a Nov. 2 CMPI release.

"By encouraging seniors to use generics, these plans have added more drugs to their formularies and kept co-pays for newer medicines low," CMPI claims. "As a result, seniors will actually have a wider choice of drugs and lower out-of-pocket expenses next year--which is the opposite of the impression given by the Families USA report."

Families USA's report, which the group says it based on data from CMS' "Landscape of Plans," is available on the group's Web site at: www.familiesusa.org/assets/pdfs/medicare-donut-hole-nov-2006.pdf.