Aug. 29--WASHINGTON -- The battle is under way in a debate that will affect millions of seniors: which and how many classes of drugs should be covered by the new Medicare prescription drug benefit.

The outcome will determine the extent to which the program pays for a host of expensive, new brand-name drugs or promotes older, cheaper, established medications and generic equivalents.

In the end, the program will have to balance quality drug coverage for Medicare’s 41 billion seniors against the ability of U.S. taxpayers to fund the most costly new Medicare benefit in 40 years.

The Bush administration estimates that the program, which kicks in January 2006, will cost $534 billion through 2014. Thereafter, as the number of baby boomers eligible for Medicare increases, so will the program’s cost and possibly the ire of seniors if they don’t like the program.

Coverage will be paid for by Medicare but delivered by private health plans and pharmacy benefit managers, or PBMs -- companies that manage drug plans for employers. The Medicare Modernization Act requires those providers to pay for at least two drugs in each therapeutic class of drugs, such as antidepressants, antibiotics and diuretics.

Each plan’s list of covered drugs, known as a formulary, must include a “full range of drug therapies necessary to adequately support current medical practice,” according to a recent Medicare position paper.

“ The idea is to make sure your beneficiaries have access to the latest and greatest drugs out there and that plans have the opportunity to offer robust formularies,” said Health and Human Services spokesman Bill Pierce.

Doing that and keeping the program affordable won’t be easy. To ease costs, plans are likely to require seniors to pay a greater out-of-pocket share for more expensive drugs or they’ll restrict access to those medications until physicians verify that cheaper medications don’t work as well on individual patients.

Within eight to 10 years, Medicare spending on the benefit is certain to soar, said Gail Wilensky, an economist and former chief of Medicare.

“ At that point, it will become increasingly apparent that we have made a lot of promises that we haven’t figured out how to finance,” said Wilensky, now a senior fellow at Project Hope, an international humanitarian health group in Millwood, Va.

Wilensky doesn’t expect lawmakers to wrestle with the budget implications until problems arise.

“ It’s hard to get politicians to make difficult choices that no one’s going to thank them for, especially when there’s pressure by current (Medicare) users who want more coverage,” she said.

Having fewer drug classes would require more medications to be lumped into the same category and thereby increase competition among drug makers to get their products included on a plan’s formulary, according to Ignagni. That would give insurers and PBMs more leverage in negotiating price discounts and save taxpayers money.

Drug companies want Medicare to cover more than 200 classes of drugs. Pharmacopeia’s 146-class plan “fails to provide patients with critical medicine options,” according to a statement from the Pharmaceutical Research and Manufacturers Association, the leading drug industry trade group. That could hurt care, the group said.

While most patients would be fine on the older drugs, “there’s always going to be some patients, maybe 20 percent or 30 percent or more, that don’t respond to those treatments. That’s why most physicians prefer (plans) with the widest range of choices available,” Jacobs said.

To ensure that similar new and expensive drugs will be strongly considered for coverage by Medicare, the committee that drafted the proposal included recommended medications that are essential to the Medicare formulary, said William Zerould, Pharmacopeia’s vice president.

After a public comment period, Pharmacopeia will submit a final proposal to Medicare officials by Dec. 31 that includes specific drugs the benefit should cover.

Medicare officials have the final say and are expected to complete their formulary in early 2005.

Article courtesy of Soldotna Professional Pharmacy · 262-3800