Safeguard Expires for Uncovered Prescriptions for Many Patients in New Medicare Drug Plan

Medicare officials are hoping to avoid another round of frustrating problems at pharmacy counters, as an important protection expires today for many patients in the new prescription program.

The safeguard allowed patients who joined the drug plan when it was launched Jan. 1 to receive a 90-day supply of medications even if the specific drugs they needed were not covered by their insurer. That provision will no longer apply, though Medicare Administrator Mark B. McClellan said some patients had not found substitute medications covered by their plans.

Drug plans will be required to make sure patients switch safely to new medications or continue to receive their current ones if medically necessary, McClellan said. Insurers that allow patients to fall through the cracks could be fined or suspended from the program, he warned.

At least some insurance programs have notified patients and their doctors of the need to prepare for the impending change.

“The transition doesn’t just happen by a patient showing up at the pharmacy counter having no information about the need to switch drugs,” said McClellan. “This is a process the drug plans are required to manage effectively.”

Under the new Medicare prescription drug plan, individual beneficiaries choose from a large number of private insurers that provide coverage; each plan offers different combinations of premiums, co-payments, lists of covered drugs and other features.

Any problems are expected mainly to affect the 6 million low-income seniors and disabled people who were automatically switched to the Medicare drug plan from state-sponsored coverage. Medicare officials are bracing for the possibility that thousands of patients will file appeals, clogging the largely untested system for handling such cases.

A recent letter from Medicare to the drug plans stressed that until a patient was taking a new medication or a final decision on an appeal had been reached, “continuation of drug coverage is necessary.”

Nonetheless, advocates for the poor say they expect widespread problems.

“The great concern is that people aren’t going to be aware the drug they are taking is not covered, and they are going to end up getting told at the pharmacy,” said David Lipschutz, an attorney with California Health Advocates.

Most California residents should be insulated from such problems, at least temporarily, because Gov. Arnold Schwarzenegger has extended the state’s emergency assistance program through April 16. The emergency program continues to pay for about 10,000 prescriptions each weekday because of problems with the Medicare plan, state officials say.

“We are hopeful that [Medicare’s] preparations will work,” said Stan Rosenstein, the state’s deputy director of medical services. Although more than half the states set up emergency programs to help beneficiaries, many have not provided as much assistance as California has.

Officials with some of the leading Medicare drug plans said insurers were taking steps to prevent a repeat of the foul-ups in the plan’s launch.

Humana, the second-largest insurer, will not invoke any restrictions over the weekend. The company has sent letters to customers whose medications will no longer be covered, as well as to their doctors.

UnitedHealth Group, which sponsors the popular AARP plan, said it would phase in some drug restrictions over the next few months, and remove others.

McClellan said several insurers were following a similar approach. “They are not going to impose their requirements on all drugs on one day at the beginning of April,” he said. “They are going to phase them in.”

Although the 90-day transition period for beneficiaries who enrolled by Jan. 1 expires today, those who are currently signing up also have some protections while they get accustomed to the program. New beneficiaries are entitled to a 30-day supply of any medication not covered by their plan.