Implementation Issues
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- Plan and Health Care Provider goals are not aligned
- PDP's and MA's are rewarded for focusing on low cost drugs to all beneficiaries, while Providers are rewarded for quality of care – sometimes involving expensive technologies.
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- Conflicting goals
- Plans are required to have a tiered exemptions process for beneficiaries to get a higher-tier drug at a lower cost, but plans must grant exception when medically necessary. However, the rule denies beneficiaries the right to request a tiering exception for certain high-cost drugs.
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- Lack of standardization
- Because each plan can choose their formulary and tier levels, drugs appearing on Tier 2 in one plan may be on Tier 3 in another plan. Tier 2 drugs may have a different co-pay with different plans. There are plans with no deductibles and the coinsurance for the most expensive drugs varies widely. Some plans may insist on step therapy, which means that the patient must use generics first before the company will pay for higher priced drugs. There is an appeal process, and the insurance company is required to respond within a short timeframe, so as to not further the burden on the patient.
- Standards for electronic prescribing for Medicare Part D conflict with regulations in many US states.
Read more about this topic: Medicare Part D
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