Fight looms over Medicare drug coverage

Physician groups worry that too few medication classes will be included in drug plan formularies, thus harming patients' access to pharmaceuticals.

By Brian Vastag, AMNews correspondent. Sept. 20, 2004.

Washington -- Although Medicare's prescription drug benefit does not launch until January 2006, health plan managers, physician groups, patient advocates and the drug industry are already jockeying to have a say in one big decision: Which drugs will the plan pay for?

In late August, the U.S. Pharmacopeial Convention unveiled draft formulary guidelines that met with howls from nearly every vested group. Doctors, patient advocates and drugmakers fear that resulting formularies will exclude vital medications.

Health plans and pharmacy benefit managers, on the other hand, complain that the guidelines contain too many classes. Fewer categories would increase their negotiating leverage when purchasing drugs and result in lower prices for Medicare beneficiaries, they say.

The opposing camps voiced their concerns at an Aug. 27 meeting in Baltimore.

The proposed model has "serious deficiencies," testified Joe Cranston, PhD, a pharmacologist and director of science, research and technology for the American Medical Association.

Representatives from various physician and patients' groups pointed out particular types of drugs that might be excluded from coverage if the draft guidelines were adopted as is. Their "critical" list includes statins for high cholesterol, selective serotonin reuptake inhibitors for depression, angiotensin receptor blockers for hypertension, proton pump inhibitors for gastro-reflex disease, bisphosphonates for osteoporosis, COX-2 inhibitors for arthritis and nonsedating antihistamines.