Preserving Choice of Medications in Medicare

Mar 29, 2016

On April 7, the Medicare Payment Advisory Council (MedPAC) will vote on a proposed change to Medicare Part D that could substantially impact low-income people with mental illnesses. MedPAC is an independent Congressional agency that advises Congress on Medicare programs. The proposal they are considering would lower cost-sharing requirements for generic medications but would significantly increase cost-sharing requirements for brand medications. Many people with mental illness, particularly those with other chronic health conditions, need access to brand name medications to control symptoms, minimize side-effects and prevent drug interactions. 

In addition, MedPAC’s proposal would eliminate “protected status” for antidepressants, removing the requirement for Medicare plans to cover almost all drugs in this class. This could limit access to these medications. This plan targets only low-income beneficiaries who live at or below 135% of the federal poverty level, which is around $16,000 per year for a single adult. This proposal sets a dangerous example by targeting low-income individuals to achieve cost savings.

Below is a letter that NAMI joined with over 250 organizations in urging MedPAC not to raise cost sharing on low-income Medicare beneficiaries.

March 24, 2016


Francis J. Crosson, M.D.

Medicare Payment Advisory Commission

425 I Street, NW, Suite 701

Washington, D.C.  20001


Dear Chairman Crosson,


We are writing to urge you to not issue recommendations to Congress in support of increasing cost sharing, particularly co-pays, for brand medicines used by Low-Income Subsidy (LIS) beneficiaries in the Medicare Part D program. We also caution you in issuing recommendations that would widen the gap between generic and brand cost sharing for this population as this might trigger prescribing changes that could negatively impact care for vulnerable populations.

Recently, MedPAC and others have considered several proposals to change cost sharing for LIS populations. Specifically, MedPAC has explored increasing brand co-payments, or eliminating generic copayments as a way to encourage additional take up of generics for the LIS population. MedPAC has argued LIS enrollees tend to utilize fewer generics than their non-subsidy eligible counterparts. However, generic utilization is already high among all Part D beneficiaries and has increased every year since the program began. Further, increased cost sharing for vulnerable beneficiaries could reduce adherence, increase spending on other health care services, and worsen health outcomes.

Generic Utilization Already High in Both LIS and Non-LIS Populations

MedPAC’s own data show high generic utilization rates for LIS and non-LIS populations, with generic use steadily increasing for both groups. In 2013, 81 percent of LIS beneficiary prescriptions were filled with generics, versus 85 percent of non-LIS prescriptions, with the generic use rate growing slightly faster for LIS beneficiaries from 2012 to 2013.  An analysis of Medicare Part D claims data by the University of Maryland found almost no difference in generic utilization rate between non-LIS Part D enrollees and partial benefit LIS enrollees with diabetes. Relative to non-low income beneficiaries, LIS beneficiaries are in poorer health and often have multiple conditions or diseases and are more likely to be disabled. These differences in health status can help explain differences in generic utilization between LIS and non-LIS beneficiaries.

Higher Cost Sharing for Branded Products Could Reduce Adherence, Increase Spending on Other Health Care Services in Medicare/Medicaid

MedPAC also notes that this proposal may cause LIS enrollees to pay higher cost sharing for brand name drugs or they might not be as adherent to their prescribed treatment. We are very concerned that reduced adherence for vulnerable LIS beneficiaries would compromise patient outcomes, and raise overall Medicare costs. As already noted, LIS beneficiaries often have multiple chronic conditions, higher rates of disabilities, and more functional or cognitive impairments than non-LIS enrollees. As a result, any changes in medication can be particularly harmful for these beneficiaries.

About half of all LIS beneficiaries qualify for Medicare before age 65 due to a disability, compared to 15 percent of non-LIS beneficiaries. Overall, LIS beneficiaries tend to be in worse health than other Medicare beneficiaries, and therefore may need multiple brand medicines to treat their chronic and often complex conditions. In fact, MedPAC has noted due to the complexity of their conditions, LIS beneficiaries tend to fill more prescription than other beneficiaries, on average. This means that higher relative copays would disproportionately penalize this population.

We are also concerned that a decline in medication adherence will only lead to poorer health outcomes, which in turn will cost the Medicare and Medicaid programs even more in avoidable hospitalizations and other unnecessary medical care. We should be encouraging these patients to take the medications their doctors prescribe rather than creating barriers that could lead them to skip doses or switch medicines, which could disrupt their treatment plans.

As part of your deliberations, we encourage you to instead look at improving the appeals process for denied coverage of specific drugs. Recent findings of the CMS’ audits of plan sponsors revealed ongoing challenges related to coverage determinations, appeals and grievances (CDAG) as well as formulary and benefits administration.  CDAG violations continue to be a key driver of CMS penalties and sanctions. There are several reforms MedPAC could consider,  including improving plain language denial notices to beneficiaries, improved data collection, and up front coverage determinations as a means to enhance affordability and medication adherence for the Part D LIS population.

We appreciate your attention to this issue and look forward to working with you on these important issues. We are happy to be a resource to MedPAC as you continue your deliberations on these issues and can meet with you and the Commission staff at your convenience.



National Organizations

AIDS United

Alliance for the Adoption of Innovations in Medicine (Aimed Alliance)

American Association on Health and Disability

American Autoimmune Related Diseases Association

American Behcet's Disease Association

American Liver Foundation

American Psychiatric Association

American Psychological Association

Asian & Pacific Islander American Health Forum

Association for Ambulatory Behavioral Healthcare

Caregiver Action Network

Center for Healthcare Innovation

Children and Adults with Attention-Deficit Hyperactivity Disorder (CHADD)

Christopher & Dana Reeve Foundation

Community Access National Network (CANN)

Easter Seals

Global Colon Cancer Association

Global Healthy Living Foundation


Lakeshore Foundation

Lupus and Allied Diseases Association

Lupus Foundation of America

Malecare Cancer Support

Medical Partnership 4 MS (MP4MS)

Men's Health Network

Multiple Sclerosis Foundation

National Alliance on Mental Illness (NAMI)


National Asian Pacific Center on Aging

National Association of Nutrition and Aging Services Programs (NANASP)

National Association of State Head Injury Administrators

National Association of States United for Aging and Disabilities

National Black Nurses Association

National Council for Behavioral Health

National Council of Asian Pacific Islander Physicians

National Disability Rights Network

National Down Syndrome Society

National Grange

National Hispanic Council on Aging

National LGBT Cancer Project

National Minority AIDS Council (NMAC)

National Multiple Sclerosis Society

National Osteoporosis Foundation

National Patient Advocacy Foundation

National Stroke Association

National Viral Hepatitis Roundtable

No Health without Mental Health (NHMH)

OWL-The Voice of Women 40+


Salud USA

Schizophrenia and Related Disorders Alliance of America

Suicide Awareness Voices of Education

The AIDS Institute

The American Orthopsychiatric Association

The Arc of the United States

The Veterans Health Council

United Spinal Association

US Pain Foundation Inc

Vasculitis Foundation

Vietnam Veterans of America

Women's Institute for a Secure Retirement

State & Local Organizations

1 in 9: The Long Island Breast Cancer Action Coalition

ADAP Advocacy Association (aaa+)

Advocates for Responsible Care( ARxC)


State and Local Organizations

AIDS Alabama

AIDS Resource Center Ohio

AIDS Response Seacoast

Alzheimer's & Dementia Resource Center

Alzheimer's and Dementia Alliance of Wisconsin

Applied Pharmacy Solutions; Touro University California College of Pharmacy

Asthma & Allergy Foundation of America, New England Chapter

Autoimmune Advocacy Alliance

Behavioral Health & Wellness

Benjamin Rose Insititue on Aging

Bio Nebraska Life Sciences Assocation


Bioscience Association of WV

Brain Injury Association of Nebraska

California Chronic Care Coalition

California Life Sciences Association (CLSA)

California NAACP

California Senior Advocates League

Capital Area Agency on Aging

Caring Families Coalition

Cascade AIDS Project

Central Florida Behavioral Health Network

Charleston Parkinson's Support Group

CNY HIV Care Network

Combined Health Agencies

Community Behavioral Healthcare Assoc of Illinois

Community Health Action Network (CHAN)

Community Health Charities of Nebraska

Community Liver Alliance

Dia de la Mujer Latina

East Georgia Cancer Coalition Inc.

Easter Seals Central and Southeast Ohio

Easter Seals Massachusetts

Easter Seals North Georgia, Inc.

Eldercare Advocacy of Florida

Empower Missouri

Epilepsy Foundation

Epilepsy Foundation Heart of Wisconsin

Epilepsy Foundation Louisiana

Epilepsy Foundation of Alabama

Epilepsy Foundation of Greater Chicago

Epilepsy Foundation of Western Ohio

Epilepsy Foundation Western/Central Pennsylvania

Fair Hill Partners

Florida Psychiatric Society

Florida Society of Clinical Oncology

Florida Society of Neurology

Florida Society of Rheumatology

Florida State Hispanic Chamber of Commerce

Gay Men Aloud

Grand Prairie Services

Granite State Taxpayers

Hinds Behavioral Health Services (HBHS)

International Institute of Human Empowerment

Iowa Biotechnology Association

Iowa State Grange

Iris House, Inc.

Kaiser Clinical Research Services

Kenneth Young Center

Kentucky and Southern Indiana Stroke Association

Kentucky Diabetes Network

Kentucky Life Sciences Council

Kreider Services Inc

Lake County United

Louisiana Psychiatric Medical Association

Lupus Foundation New England

Lupus Foundation of Florida

Lupus Foundation of Southern California

Lupus LA

Lupus of Nevada, Inc.

Massachusetts Association for Mental Health

Medical Oncology Association of Southern California

Memorial Behavioral Health

Mental Health & Addiction Advocacy Coalition

Mental Health America of Eastern Missouri

Mental Health America of Montana

Mental Health Association in New York State, Inc.

Mental Health Awareness Team

Michigan Biosciences Industry Association – MichBio

Michigan Medical Group Management Association

Minnesota Rural Health Association

Missouri Association of Osteopathic Physicians and Surgeons

Missouri Biotechnology Industry Organziation (MOBIO)

Molly's Fund Fighting Lupus

Montana BioScience Alliance

MS Resources

NAADAC-The Association for Addiction Professionals

NAMI Alabama

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NAMI Central Iowa

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NAMI Clark, Greene and Madison Counties

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NAMI Johnson County

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NAMI Kane-South, DeKalb and Kendall Counties

NAMI Kansas

NAMI Kentucky

NAMI Maryland

NAMI Massachusetts

NAMI Meridian

NAMI Metro Baltimore

NAMI Mid-Carolina

NAMI Mississippi, Central Affiliate

NAMI Missouri

NAMI Montana

NAMI Nebraska

NAMI New Mexico

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NAMI NYC Staten Island

NAMI of Central Suffolk, Inc.

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