Cancer Patients With Part D Need Extra Help to Pick Plans


WASHINGTON — Physicians treating older cancer patients must actively help them choose Medicare Part D prescription drug plans with formularies that best cover not only current medications but future needs as well, health care consultant Mary Kruczynski said at a conference sponsored by Elsevier Oncology.

“Get online and check their formulary, and if [your patient] hasn't chosen a plan, think outside the box and list all the drugs they'll possibly need in the future,” said Ms. Kruczynski, a policy analyst and board member of the Community Oncology Alliance, a Washington-based lobbying group.

Although most physicians do not have time for such legwork, “the current reality is, you can't afford not to. … If we don't, our patients can't get treated,” said Ms. Kruczynski, who is based in Langhorne, Pa.

“If [your patients] go to the drug store and get told 'it's not on the formulary,' they come back to you,” she said.

When cancer drugs appear on multiple formularies, pricing variations can be significant—and physicians and staff might even want to help patients navigate such variations, especially as more and more oral drugs for cancer become available.

A recent cost study of seven oral cancer drugs in three markets documented significant variations, Ms. Kruczynski noted.

The cost of Arimidex (anastrozole), for instance, was 72% higher in Portland than in Virginia Beach (Commun. Oncol. 2006;3:753–5).

Formularies under Medicare Part D also are increasingly restrictive. Many insurers have added coverage of generic drugs and reduced coverage of brand-name drugs; some also are adopting new techniques to control the use of certain drugs.

“They're asking for data, blood counts, medical records … and checking doses,” Ms. Kruczynski said. “Some carriers now require you to get every prescription authorized.”

Those physicians who care for patients with cancer, in the meantime, have “been bending over backwards to try to get every drug our patients need for them, even if they have to switch them from Part D to Part B … even if they get them to their doughnut hole,” or coverage gap, “and bring them into the office for an infusible under Part B,” Ms. Kruczynski commented.

The Medicare Payment Advisory Commission (MedPAC) recognized such actions in its January 2007 report, she said.

The report, which focuses on Medicare payments for Part B drugs and also includes some commentary on Part D drugs, notes the word of those physicians who work with their patients to determine whether it is more beneficial to prescribe the drugs under Medicare Part D or under Part B.

One option might be preferable to the other, Ms. Kruczynski said, depending upon the patient's Part D plan and coverage. The value of one choice over another could also depend on the patient's spending relative to the doughnut hole and any catastrophic coverage that the patient might have.

The MedPAC report also relates physician accounts of patients who reach the doughnut hole and either neglect their treatment or try to stretch out their drug regimens until coverage starts again.

Concerns about patients “brown bagging” physician-administered drugs so that they can be covered under Part D—as well as observations that some physicians have established in-house pharmacies to remedy the problem—also are mentioned in the MedPAC report, Ms. Kruczynski said.

Insurance companies also are “changing their formularies midstream,” she said. That is, although Medicare drug plans are indeed permitted to retain the same name while substantially changing costs and benefits each year, the plans sometimes fail to send out the required change notices.

The UnitedHealth Group, which serves the largest segment of the Medicare Part D market, has done this in the past.

The issue of formulary changes has been included in at least some of the 42 House and 31 Senate bills addressing problems with Medicare Part D, Ms. Kruczynski noted.

MedPAC also is expected to weigh in this year with a report focused on the program.

For now, she said, “it's coming down to us again.”

By helping patients navigate Part D, “we're essentially administering the plans of private insurance carriers for free.”

In the meantime, she emphasized, that help is essential for the health of patients.

Elsevier Oncology and this news organization are wholly owned subsidiaries of Elsevier.

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