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Medicare administrator responds to Knight Ridder article

To the Editor:

Your story about the Medicare prescription drug coverage missed the point that the new coverage is working for millions of seniors who are getting their prescriptions filled every day.

With many millions of prescriptions being filled, we have seen a low number of appeals to our independent reviewer, and low rate of complaints so far about how plans are handling these requests.

Medicare prescription drug plans are required to cover all medically necessary drugs and when a specific drug is not covered, Medicare requires that generic equivalents or other drugs that work in very similar ways to treat the same condition are covered. When used properly, preferred drug lists can significantly reduce the cost and improve the safety and effectiveness of drug therapies. Consumers Union recently found that using these lower-cost drugs can save seniors hundreds or thousands of dollars a year. Virtually every health insurance program has these similar features—but usually stricter, with fewer drugs covered than in Medicare, and almost never with the right of beneficiaries to appeal these restrictions.

In those cases when beneficiaries need a drug that is not covered, Medicare drug plans must act quickly. We have been monitoring complaints to make sure that happens. Where complaints have occurred, we have generally been able to resolve them on a case-by-case basis, but we will take further enforcement actions against plans if there are ongoing patterns of problems.

We are also making sure that beneficiaries know about and use their rights to ask for a drug that is not covered or appeal a decision they don't like. We are working closely with physicians and physician groups to make sure they understand their role to help beneficiaries by ensuring the drugs they prescribe are on a plan's formulary, just as they do for their other insured patients. Because of these steps, the vast majority of seniors with drug coverage say that it is working for them.

Dr. Mark McClellan


Centers for Medicare & Medicaid Services


(c) 2006, Knight Ridder/Tribune Information Services.

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