Forum Session

Medicare Drug Utilization Management: Balancing Cost, Convenience, and Access
October 19, 2007


Mary Ellen Stahlman


Health plans, including Medicare prescription drug plans, use a variety of tools to manage prescription drug use and costs. The utilization management tools that plans use include quantity limits, refill limits, generic substitution, therapeutic substitution, prior authorization, step therapy, and restrictions on the use of off-label drugs. These tools are very effective in reducing drug costs, preventing clinical mistakes, and helping ensure that enrollees receive the most appropriate medication for their particular condition. They can also inconvenience beneficiaries—or worse, impair ready access to needed drugs. And the appeals processes designed to ensure the resolution of disputes between plans and beneficiaries are thought by many to be impractical or too difficult for typical beneficiaries to understand. This Forum session explored whether Medicare Part D has achieved the right balance of cost containment, convenience, and access. Speakers included a Medicare drug plan senior manager, a practicing physician, a community pharmacist, and a counselor who helps low-income beneficiaries navigate all of these issues.


Daniel C. Lyons, MD, Senior Vice President, Government Programs, Independence Blue Cross; Holly King Morris, Pharmacist, Crittenden’s Drug; Robert P. Smith, MD, Physician, Richland Medical Center; Suzanne H. Jackson, JD, Director, Health Insurance Counseling Project, and Associate Professor of Clinical Law, George Washington University Law School

Slides from the presentations by Dr. Lyons, Dr. Smith, and Ms. Jackson are available for download. Suggestions for practical solutions for pharmacists, by Ms. King Morris, are also available.

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