Medicare: Medication Access

The Issue:  Medicare Medication Access, “Six Protected Classes”

Where We Stand:

NAMI believes that people with mental illness deserve access to effective medications that treat their mental illness. Specifically, NAMI supports Medicare’s successful “six protected classes” policy, which ensures that people with the most complex conditions have access to a broad spectrum of medications.

Why We Care:

Access to needed prescription medications is essential for many people with mental illness to successfully manage their condition and get on a path of recovery. Medicare is the lifeline for much of that care, accounting for about one-fifth of all mental health spending nationally.

Congress established Medicare Part D in 2003 to provide much-needed prescription drug coverage for seniors and people with disabilities, including people with mental illness. The current policy requires all Part D prescription drug plans and Medicare Advantage plans to include “all or substantially all” of the medications in the six protected classes on their drug formularies, including antidepressants and antipsychotics. This policy is a key part of the success of Medicare Part D because it established critical medication access protections for many of the most vulnerable Medicare beneficiaries – including those living with mental illness.

Medicare’s six protected classes policy:

  • Supports Medicare beneficiaries with mental health conditions;
  • Ensures that individuals with the most complex conditions have access to a broad range of clinically appropriate medications;
  • Helps prevent more costly health care interventions; and
  • Protects beneficiaries’ continuity of care for the medication that works best for them.

How We Talk About It:

  • Millions of people with mental illness rely on Medicare as a lifeline for treatment, including a way to access needed prescription medications.
  • Although it may not always be a part of an individual’s mental health treatment, medication can be a valuable tool in a person’s recovery.
  • For individuals who do take medications for their mental health condition, one size does not fit all. Mental health medications affect people in different ways, and an individual needs to be able to access the medication that works best for them.
  • Adding obstacles like step therapy (also known as “fail first”) or prior authorization hurts people with mental illness by delaying needed treatment, while increasing the burden on providers.
  • Medicare’s six protected classes policy was created to ensure that Medicare beneficiaries with some of the most complex conditions like mental illness are not discriminated against, as well as making sure they have access to a range of treatment options that meet their individual needs.
  • The six protected classes policy guarantees that the 43 million Medicare beneficiaries have access to the medications that their health care provider prescribes, including antipsychotics and antidepressants.
  • Weakening the six protected classes policy would reduce access to medications, interrupting people’s lives and threatening their recovery and safety.

What We’ve Done:

  • NAMI’s comments on the importance of the Six Protected Classes Policy
  • NAMI’s statement on Medicare Part D recommendations
  • NAMI’s statement on preserving Medicare Part D access to psychiatric medications
  • NAMI’s statement on medication choice