February 21,2008

Finance Leaders Aim To Help Seniors Seeking Additional Coverage From Their Medicare Drug Benefit Plans

New GAO report recommends improvements to help seniors appeal when certain prescriptions are not covered by drug plans

Washington, DC – Senate Finance Committee Chairman Max Baucus (D-Mont.), Ranking
Republican Chuck Grassley (R-Iowa), Health Subcommittee Chairman Jay Rockefeller (D-W.
Va.), and Ranking Republican Orrin Hatch (R-Utah) today commented on a new Government
Accountability Office (GAO) report recommending that both the Centers for Medicare and Medicaid Services (CMS) and private drug coverage plans do more to improve the appeals
process for beneficiaries seeking coverage for a drug not included in their plan. Under the
benefit, beneficiaries can ask for coverage of prescriptions restricted under their plan through a
process known as a coverage determination, and can appeal that decision if they are denied. In
today’s report, the GAO recommends that plans provide more assistance to seniors appealing for
coverage, and that CMS do more to monitor how plans reach decisions on those appeals.

“We’ve got to make sure that seniors get a fair shake when plans decide what drugs to cover. This report makes clear that more needs to be done to make certain that the coverage plans provide is working for seniors,” Baucus said. “The process by which folks can appeal to have additional prescriptions covered is one of the most important ways the Medicare drug benefit responds to seniors’ needs. It ensures that seniors have access to the drugs their doctors prescribe. I am going to keep a very close eye on how plans determine drug coverage, and to make sure the drug benefit is serving seniors in the best way possible.”

“The Part D appeals process was carefully constructed to allow beneficiaries to get the drugs they need for their care when other drugs will not work,” Grassley said.

“It’s important that the appeals process function as intended. That goal needs to be balanced with the need to preserve formularies' relevance to hold down prescription drug prices. Better oversight by CMS is needed to ensure that plans are responding promptly and appropriately to beneficiary appeals. CMS needs to do a better job of educating beneficiaries on their appeals rights.”

“Patients and their doctors should not have to navigate an impossible maze of bureaucratic
red tape in order to get the prescription drugs they need,” Rockefeller said. “Not only does
CMS need to consider expanding the list of prescription drugs covered by Medicare, but they must also improve the appeals process so that inconsistencies are eliminated and everyone is treated fairly. We will continue to monitor CMS’s implementation of the recommendations included in this report.”

“When we wrote the Medicare Modernization Act of 2003, it was very important to me that
beneficiaries have a choice of plans that offered prescription drugs at an affordable price,”
Hatch said. “We included an appeals process in the law so that if a specific drug was not
covered by a plan, there was a mechanism in place to help beneficiaries get the drugs that
they need. This process can be confusing at times so I agree with the GAO’s recommendation that both the drug plans and CMS need to make the appeals process more user friendly for beneficiaries.”

The GAO report titled MEDICARE PART D: Plan Sponsors’ Processing and CMS Monitoring of Drug Coverage Requests Could Be Improved was requested by Senators Baucus, Grassley, Rockefeller and Hatch. The report is posted on the GAO website at www.gao.gov.

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