Medicare Medication Access, “Six Protected Classes”

Where We Stand

NAMI believes that all people with mental health conditions deserve access to effective medication and treatment options. NAMI supports Medicare’s “six protected classes” policy to ensure access to a broad range of antipsychotic and antidepressant medications.

Why We Care

Access to effective prescription medications is essential for many people with mental illness to successfully manage their condition and get on a path of recovery. Medicare is a lifeline for much of that care, providing health insurance for over 60 million U.S. adults, including millions of people with mental health conditions and accounting for about one-sixth of all mental health spending nationally.

In 2003, Congress established Medicare Part D which allows Medicare coverage of outpatient prescription drugs. This change provided much-needed prescription drug coverage for seniors and people with disabilities, including many 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 “six protected classes” on their drug formularies. Two of the six protected classes are antidepressants and antipsychotics. This policy was created to ensure that Medicare beneficiaries with some of the most complex conditions, like mental illness, are not discriminated against. It also ensures they have access to a range of treatment options that meet their individual needs.

Medicare’s “six protected classes” 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 and must be maintained.

How We Talk About It

• Millions of people with mental illness rely on Medicare as a lifeline for treatment including access to 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 take medications for mental health conditions — one size does not fit all. Mental health medications affect people in different ways. People need access to the medications that works best for them.
• Requiring step therapy (also known as “fail first”) or prior authorization, means that there are extra administrative steps that must be taken before a person can access the medication they need. This 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. It also ensures they have access to a range of treatment options that meet their individual needs.
• The six protected classes policy guarantees that Medicare beneficiaries have access to the exact medications they need, 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 is part of a coalition called Partnership for Part D Access and our advocacy work with that coalition can be found here
• NAMI comments on the importance of the Six Protected Classes Policy
• NAMI statement on Medicare Part D recommendations
• NAMI statement on preserving Medicare Part D access to psychiatric medications
• NAMI statement on medication choice