Protection & Advocacy Inc.

 

Advancing the Rights of Californians with Disabilities

LEGISLATION & PUBLIC
INFORMATION UNIT

1029 J Street, Suite 150
Sacramento CA 95814
Telephone: (916) 497-0331
Fax: (916) 497-0813
www.pai-ca.org

 

Pharmacy Benefit Principles

Adopted 3/11/2005

 

During this legislative session, Protection and Advocacy, Inc. will need to weigh in on a number of bills related to the implementation of Medicare Part D prescription drug coverage. Medicare Part D, which goes into full effect on January 1, 2006, will provide limited prescription coverage to Medicare beneficiaries and will replace Medi-Cal pharmacy coverage for persons with disabilities who are “dual eligibles”, i.e. those clients who have both Medicare and Medi-Cal. The process of transitioning dual eligibles from Medi-Cal pharmacy coverage to Medicare Part D is fraught with potential problems. Medicare Part D will also significantly impact the way in which medications are provided to Medicare beneficiaries who are in long-term care.

In addition, there are a number of proposals that the Legislature is likely to consider to make prescription drugs more affordable for Californians. Some of these proposals may seek to pressure pharmacies to make drugs affordable by imposing Medi-Cal prior authorization requirements on pharmacies that do not comply with new State purchasing requirements.

Because of the sheer volume of bills related to Medicare Part D implementation and other drug initiatives, and the likelihood that the substance of these bills will change often and significantly as they go through the legislative process, the Benefits Workgroup asks that the board approve a set of Pharmacy Benefit Principles for PAI staff to use in analyzing and taking positions on these bills. These principles are as follows:

1.       Necessary drugs of choice should be available.

·     Drug formularies should be as broad and comprehensive as possible so that doctors can prescribe the widest choice of drugs consistent with the individual’s preference. This recognizes the fact that not all drugs work for all people, and individuals may prefer to try different medications in an effort to find the one that works best for them.

·     There must be reasonable procedures for obtaining drugs that are not listed on a particular insurer drug formulary. This might include a prior authorization or review process that is not overly burdensome on beneficiaries or providers.

·     Drug classifications that arbitrarily limit the number of classes of drugs, and the number of drugs per class should be avoided. For example, a formulary that establishes a classification for “antidepressants” but then further limits the available number of antidepressants to two would be unacceptable.

2.       Necessary drugs should be accessible.

·     Any State-sponsored drug program should ensure that a sufficient number of pharmacies participate so that drugs are available at pharmacies near the beneficiary’s residence.

·     Drug programs must ensure drugs are available by mail order and over the internet, and by way of home delivery, if necessary.

·     Comprehensive access to prescription drugs should be available for dually eligible beneficiaries in the Medi-Cal and Medicare Part D programs to meet their medical needs.

·     There should be timely and meaningful eligibility dispute resolution for individuals, including dual eligibles, and continued coverage for medically necessary medication during the dispute resolution process.

·     Initiatives will be supported  to help ensure the uninterrupted provision of medically necessary drugs to Medicare beneficiaries currently receiving medication through long-term care specialty pharmacies

·     Freedom of choice must be available for beneficiaries of the Medicare Part D program in the initial selection of an appropriate provider as well as their right to reenroll with other participating providers at any time in the future.

·     Information to beneficiaries of the Medicare Part D program must be made available in a timely manner and in a format and language that enables them to understand the terms and conditions of the new program and to make informed decisions about their health care needs.

·     PAI supports initiatives to prevent any loss of prescription drug coverage for beneficiaries who will be switching from Medi-Cal to Medicare under the Medicare Part D program.

3.       Necessary drugs should be provided on a basis that does not discriminate against classes of beneficiaries.

·     The State should not leverage drug prices by imposing prior authorization under the Medi-Cal program on nonparticipating pharmacies.

·     Drugs should be available regardless of medical condition. This includes drugs for HIV/AIDS, psychiatric conditions, and severe pain.

·     To the extent permitted under federal law, the State should provide the same drug benefit to individuals dually eligible for Medi-Cal and Medicare as is available to individuals who are beneficiaries of Medi-Cal only.

·     Legislation, regulation and policy initiatives related to California’s implementation of Medicare Part D must not impinge upon individuals’ right to informed consent.

·     PAI continues to oppose forced treatment of individuals with disabilities. Nothing in the legislation, regulation and policy initiatives related to California’s implementation of Medicare Part D should promote or encourage the expansion of involuntary treatment.

4.       Necessary drugs should be affordable.

·     The State should participate in purchasing arrangements that enable it to obtain drugs at the lowest possible cost consistent with availability, access, and non-discrimination.

·     The State should ensure that individuals who need maintenance drugs, a number of drugs, or drugs for chronic conditions are able to obtain a reasonable supply and without undue cost.

·     The State should ensure that insurance premiums, deductibles, coinsurance or co-payments are not unduly burdensome so that beneficiaries can afford the drugs they need.

 

Policy #1026.01

Adopted 3/11/2005