For several reasons, access to medications for dual eligibles will be more limited under the new plan than under their state’s Medicaid program. For instance, under federal law, states that provide prescription coverage are required to cover “most” FDA-approved drugs for all manufacturers that have entered into an agreement with the Secretary of the Department of Health and Human Services (DHHS) to pay rebates to states for the products they purchase. This stipulation allowed dual eligibles access to a more “open” formulary than is commonly available from most Medicare plans. Although states have been implementing tools to control utilization (such as prior authorization requirements, limiting the number of prescriptions, and charging nominal co-pays), Medicaid formularies are considered open formularies.

With regard to charging a nominal co-payment, the burden is on the provider, for providers are not allowed to deny services to Medicaid beneficiaries who cannot make these payments. This is not true under Medicare Part D, in which plans can withhold prescriptions to any beneficiary, including the dual eligibles, for failure to pay $1.00 for their generic prescriptions and $3.00 for brand-name prescriptions. This change will certainly result in some dual eligibles not receiving needed medications. canadian antibiotics

Pharmacies can choose to waive co-pays and dispense medications if the patient cannot pay and if the following conditions are met:

• The pharmacy does not advertise that it will waive co-payments.
• The pharmacy does not routinely waive co-payments.
• The pharmacy waives the co-payment only if the patient is in financial need.

Fortunately, patients who are fully dual-eligible beneficiaries and who reside in long-term care facilities will not be required to pay any co-insurance for formulary prescription drugs. The critical word is “formulary,” because not all prescription drugs will be included on a plan’s formulary. Some medications will be restricted by the plan; still others are not covered by the MMA legislation because they are not available under Medicare Part D.

These medications were excluded because the MMA’s drafters relied on a definition of Medicare Part D drugs from the list of medications that state Medicaid programs offering prescription drug coverage are required to cover. Although all 50 states now cover these medications to some degree, they are not required to do so under the current Medicaid law. As a result, Medicare PDPs are not being required to cover these medications either, nor can they cover them using Medicare Part D funds because of the way in which the law was drafted.
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States can decide to cover those medications that are excluded by the MMA rules because of their classification as non-Medicare Part D medications, and although some states (e.g., Delaware, Colorado, Illinois, and Maryland) have passed bills to provide funding for these excluded medications, some states may choose not to provide such coverage.

The MMA excludes certain medications from Medicare Part D coverage according to their drug class and use:

•  Specific excluded classes: 1 over-the-counter drugs barbiturates
1 benzodiazepines
1 vitamins (except prenatal)
•  Specific excluded uses:
1 weight enhancement or reduction (except when the medication is used to treat obesity or weight enhancement in patients with acquired immunodeficiency syndrome (AIDS)
1 fertility
1 cosmetic enhancement (e.g., minoxidil [Rogaine®] and generic isotretinoin (Acutane canadian) 1 symptomatic relief of cough or colds

Of these medications excluded under MMA, the drug class most commonly utilized by dual eligibles is the benzodiazepines. Because of this need, a bipartisan bill was introduced to strike the exclusion of benzodiazepines that currently exists in the MMA. Representative Benjamin Cardin (D-Md.) introduced H.R. 3151, which has been referred to the Committee on Energy and Commerce and to the Committee on Ways and Means for consideration. Obviously, this would remove this burden not only from states but also from individual Medicare beneficiaries, who would be forced to cover this excluded medication on their own if they needed it.

An additional concern regarding excluded medications is that the exclusions will force a shift to drugs covered under Medicare Part D. This change might not always be appropriate and might result in adverse drug reactions and increased expenditures.