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Medicare drug plans cover a good selection of drugs for nursing home residents, but plan vigilance should continue

The Medicare Part D drug plans (PDPs) provide nursing home residents with reasonably broad coverage across different drug classes, with minimal prior authorization requirements. However, a minority of PDPs are less generous, and some drug formulations important to nursing home residents are covered less well, note the Harvard Medical School researchers.

Using national data that reflect initial coverage in Part D, they analyzed PDP formularies and utilization management practices across several categories of drugs commonly used by nursing home residents and older people. They focused on PDPs to which individuals dually eligible for both Medicaid and Medicare could be auto-assigned (those with premiums at or below regional benchmarks). PDPs are required to cover at least two drugs in each therapeutic class. However, they must cover all drugs in six "protected" classes, such as antidepressants, antipsychotics, and HIV-related drugs.

Of the nonprotected drug classes, 69 percent of plans covered at least four of five Alzheimer's medications. Most plans also covered at least three of four bisphosphonates (76 percent), at least three of five proton pump inhibitors (86 percent), and at least four of six statins (61 percent). Nevertheless, 11 percent of plans covered only one or two of the six statins. The majority of plans required no prior authorization for covered medications in six of seven classes reviewed (except bisphosphonates).

A minority of plans, once again, were more stringent. For example, 22 percent and 9 percent of PDPs required prior authorization for all covered Alzheimer's drugs and proton pump inhibitors, respectively. Random assignment of dually eligible residents to below-benchmark plans means that some residents will initially be enrolled in these more restrictive plans, and may find it difficult to identify and switch to a more appropriate plan. Thus, the researchers recommend vigilance to protect these frail Medicare patients as the transition to Part D proceeds. Their study was supported in part by the Agency for Healthcare Research and Quality (HS10803).

More details are in "Medicare Part D and nursing home residents," by David G. Stevenson, Ph.D., Haiden A. Huskamp, Ph.D., Nancy L. Keating, M.D., M.P.H., and Joseph P. Newhouse, Ph.D., in the July 2007 Journal of the American Geriatrics Society 55, pp. 1115-1125.

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