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Medicare Part D provides coverage protection for mental health-related drugs, but certain drugs still may not be covered

Legislation in 2003 created Medicare Part D, a voluntary prescription drug benefit available to all Medicare beneficiaries. Health plans are required to cover a minimum of two drugs in each therapeutic drug class. However, plans must cover "all or substantially all" distinct drugs in three psychotropic (mind-altering) drug classes: antidepressants, antipsychotics, and anticonvulsants. Health plans are not required to cover both the generic and brand version of the same drug.

These special protections afforded to these drug classes under the Part D benefit will help to ensure that Medicare beneficiaries with a mental illness have access to needed medications. However, despite these protections, certain product formulations may not be covered, according to a new study.

Prescription drug plans serving individuals dually eligible for Medicare and Medicaid programs generally covered at least one formulation of all three of these drug classes. However, certain drug formulations were not covered by a number of plans, and use of prior authorization was common for a minority of plans. Thus, the effect of Part D will depend on the restrictiveness of the prior authorization of health plans and appeals processes, which is currently unknown, concludes Haiden A. Huskamp, Ph.D., of Harvard Medical School.

Dr. Huskamp and coinvestigators analyzed data from the Center for Medicare and Medicaid Services for all private prescription drug plans as of December 2005, which reflected coverage at the inception of Part D. They examined drug coverage and prior authorization policies of 519 prescription drug plans to which dual eligibles could be autoenrolled as of December 2005. Although a majority of plans did not require prior authorization for covered drugs in the three psychotropic drug classes, a sizable minority of plans required it for specific medications.

Also, use of prior authorization varied considerably across drugs within a class. For example, use of prior authorization for plans that covered second-generation antipsychotics ranged from 8 percent for Clozaril® to 48 percent for Zyprexa IM®. Use of prior authorization was more common for covered second-generation antipsychotics and anticonvulsants than for antidepressants.

The study was supported in part by the Agency for Healthcare Research and Quality (HS10803).

See "Coverage and prior authorization of psychotropic drugs under Medicare Part D," by Dr. Huskamp, David G. Stevenson, Ph.D., Julie M. Donohue, Ph.D., and others, in the March 2007 Psychiatric Services 58(3), pp. 308-310.

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