Medicare Part D and Nursing Home Residents

Abstract

The objective of this study was to analyze national Part D formulary data to assess adequacy of coverage across seven drug classes commonly used by nursing home residents and older people, focusing on individuals dually eligible for Medicare and Medicaid and plans in which they enroll. Focusing at the molecule level, reasonably broad coverage across drug classes and minimal prior authorization overall was found. Of nonprotected classes, 69% of plans cover at least four of five Alzheimer's medications, 76% cover at least three of four bisphosphonates, 86% cover at least three of five proton pump inhibitors, and 61% cover at least four of six 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). Nevertheless, a minority of plans are less generous, and some drug formulations important to nursing home residents are covered less well. For example, 11% of plans cover only one or two of the six statins. Of protected drug classes, plans generally cover all molecules, as expected. The majority of plans require no prior authorization for covered medications in six of seven classes reviewed (excepting bisphosphonates). A minority of plans once again are more stringent. For example, 22% and 9% of Part D Plans nationally require prior authorization for all covered Alzheimer's drugs and proton pump inhibitors, respectively. Random assignment of dually eligible patients to below-benchmark plans means that some residents initially will be enrolled in these more-restrictive plans. Part D allows nursing home residents to switch plans at any time, but there are important barriers to residents' self-advocacy. Finally, it is unclear how well nursing homes and the pharmacies they work with will work across Part D plans, and vigilance will be required as the benefit proceeds.