Dr. Smith, who, with the aid of a nurse practitioner, maintains a solo practice that serves the entire northern half of New Mexico, believes the “system discriminates against those with chronic disease.” Because 40% of Dr. Smith’s practice load is eligible for coverage under Part D, she is familiar with the problems of an aging population with chronic disease.
Christopher Morris, MD, objects to using generic drugs simply to meet the coverage requirement. Dr. Morris is part of a practice that includes three physicians and five physician’s assistants, working out of Kingsport, Tenn., and covering a large area of southern Appalachia. He and his colleagues serve both an urban area and a more rural community.
Dr. Morris is dismayed that so many patients are asked to switch to a generic brand even though their current treatment is quite successful. “I am shocked by the number of patients requiring prior authorization for state-of-the art medications that have been successfully treating their conditions all along,” says Dr. Morris.
John Goldman, MD, a solo practitioner in Atlanta, also takes a strong stand on the question of generic drugs. He questions the testing procedures for determining the equivalency of a generic drug. “Generic drugs are tested by normal, healthy volunteers—not patients,” claims Dr. Goldman. “The generic drug can’t automatically be assumed to be a satisfactory substitute.”
His opinion of generic equivalency can be summed up with the question in the title of his article in the ACR Practice View: “Generic Drugs: Should bioequivalence be equated with therapeutic equivalence?”1
Do Your Patients Know?
- All Medicare beneficiaries—regardless of income—are eligible for Part D.
- A plan cannot discourage enrollment by certain Medicare beneficiaries, meaning plans cannot select the healthiest Medicare beneficiaries who are thus likely to have the lowest medical costs.
- The plan is good for one year at a time, therefore there is a deductible and doughnut hole every year.
- Even if a prescribed drug is removed from the plan’s original formulary before a beneficiary’s year is up, the beneficiary is guaranteed to receive the medication for 12 months.
- Congress specifically barred supplemental insurance plans from covering the doughnut hole (although some plans may cover some expenses in the doughnut hole but often limit coverage to mail-order generic drugs).
- Money spent by patients out of their own pockets for an excluded drug does not count toward a plan’s deductible.
- Even if a drug is included in a plan’s formulary, it may not be covered at a standard rate.
- Low-income beneficiaries can avoid extra charges only if they sign with plans whose premiums are equal to or lower than the state average. Otherwise, they have to pay the difference between the state average premium and their selected plan’s premium.
Cost Sharing and Drug Formularies
Rheumatologists must work with cost-sharing systems and utilization management tools daily, and working with the formularies can be a daunting task. In the first place, Medicare’s private, stand-alone plans vary significantly in regard to covered drugs, out-of-pocket co-payments for certain medications, and restrictions on the use of certain medications.
