BACKGROUND: Medicare Part D was introduced with a goal of providing access to prescription drug coverage for all Medicare beneficiaries. Regulatory mandates and the changing landscape of health care require continued evaluation of the state of the Part D benefit.
OBJECTIVE: To review the current state of plan offerings and highlight key issues regarding the administration of the Part D benefit.
SUMMARY: The Part D drug benefit continues to evolve. The benefit value appears to be diluted compared to the benefit value of large employer plans. Regulatory restrictions mandated by the Centers for Medicare and Medicaid Services (CMS) are reported to inhibit the ability of plans to create an effective, competitive drug benefit for Medicare beneficiaries. Management in this restrictive environment impedes competitive price negotiations and formulary coverage issues continue to create confusion especially for patients with chronic diseases. The doughnut hole coverage gap represents a significant cost-shifting issue for beneficiaries that may impact medication adherence and persistence. To address these and other challenges, CMS is working to improve the quality of care for Part D beneficiaries by designing and supporting demonstration projects. Although these projects are in different stages, all stakeholders are hopeful that they will lead to the development of best practices by plans to help manage their beneficiaries more efficiently.
CONCLUSIONS: A significant number of Medicare beneficiaries are currently receiving prescription drug benefits through Part D. The true value of this benefit has been called Into question as a result of plan design parameters that lead to cost-shifting, an Increasing burden for enrollees. Concerns regarding the ability to provide a competitive plan given the stringent rules and regulations have been voiced by plan administrators. In an effort to drive toward evidence-based solutions, CMS is working to improve the overall quality of care through numerous demonstration projects.