A large portion of the population is aging out of private health care and into Medicare coverage, and with that shift comes a growing enrollment in Medicare Advantage plans. Coverage for Medicare Advantage plans comes through private companies approved by Medicare.
Also called “Part C” or “MA Plans,” a Medicare Advantage Plan offers coverage for all of your Hospital Insurance (Medicare Part A) and Medical Insurance (Medicare Part B). A Medicare Advantage Plan covers everything Original Medicare would, with the exception of hospice.
In recent weeks, the freedoms available under Medicare Advantage for the next year have fallen under speculation.
Will Medicare Advantage Plans Cut Choices?
The short answer is yes. Benefits Pro
just reported that starting next year, a Medicare Advantage Plan can start adding restrictions to injectable drugs used to treat rheumatoid arthritis
, macular degeneration, cancer, and other serious illnesses.
The concern is that these restrictions might enable private Medicare insurance plans to try cheaper versions of drugs before they’re allowed to use the ones their physicians are prescribing.
The Disadvantage to Medicare Advantage
Speculation has been raised that elderly and more infirm patients might be endangered under these new restrictions. Depending on the patient’s condition, being unable to immediately seek their doctor’s first choice in prescription drugs could be the difference between life and death.
These constrictive stipulations are part of the current administration’s attempt to deliver on promises of lower drug prices. And while the Medicare Advantage Plan patients are certainly being offered cheaper drugs, these Medicare Advantage restrictions create a grey area. There is currently no threshold to determine when the cheaper-tier drugs are deemed “ineffective” and patients can being pursuing their doctor’s initial prescription.
The Path Forward
Benefits Pro reports that Federal health officials told insurance providers last month that they were cleared to substitute a less expensive Part B drug to treat a medical condition the FDA has not approved it for so long as it could be documented that the drug was safe and effective.
Patients that do not want to risk trying the cheaper drug first have two options: an appeal, or an exemption, although their physician’s support is needed to continue. The physician will need to explain the situation to the insurers and provide heavily detailed documentation as to why their patient needs to have the more expensive, top-tier drugs. The insurance plans then have 24-72 hours to respond to these appeals and exemption requests. You read a more detailed description of the appeals process here.
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