Patients, even those who benefit from Part D prescription drug coverage, encounter many of the same frustrations that face their rheumatologists. Phyllis, a retired New York teacher with RA now living in California, has worked out a plan that combines Part D coverage with her New York retirement coverage to handle the financial costs, but she is frustrated with Part D’s restrictions on self-injections and infusions and the prior authorization required for oral medications. She considers herself fortunate to be in good health except for RA, but she thinks the administration of Part D is unnecessarily complicated.
Another patient, Chuck, turned to his state—Illinois—seeking prescription drug coverage and discovered that once he proved he qualified, state coverage was more comprehensive and less confusing than signing up for Part D,so he chose not to enroll. However, Chuck manages a support group for arthritis patients and tries to help his members navigate through Part D enrollment.
He reports that his members find Part D extremely confusing. Many, for example, do not understand that Part D is renewed each year and that, therefore, the doughnut hole (the gap in coverage during which all of the expensive rheumatic medications are paid for out-of-pocket) reappears annually—knowledge gaps are as widespread as doughnut hole gaps, he notes.
One of the most commonly mentioned concerns of rheumatologists is their perception that following Part D guidelines may interfere with the practice of medicine and their ability to provide optimal patient care using the most appropriate medications (within cost-containment guidelines) for each patient.
The frustration most often mentioned by the rheumatologists is the need for prior authorization to use a drug not on a plan’s formulary.
Rheumatologists in particular use medications that don’t fall neatly into government guidelines. These drugs have more than one indication, are often expensive, and may be used on a long-term basis. Any or all of these factors may make prescribing a challenge—a drug may not be listed in a formulary or may require extra paperwork for coverage. Such problems begin with the questions of generic equivalents, cost-sharing requirements, and drug formularies in general.
Many rheumatologists say their treatment choices are compromised when the plan coverage requires automatically switching to a generic form of a medication or a less expensive treatment option. “Forcing a drug choice to be a generic equivalent may be acceptable,” says Fredrica Smith, MD, “but it should be a medical decision, not a government mandate.”