Medicare Part D Formularies, 2006‐2010
Elizabeth Hargrave
NORC at the University of Chicago
NORC at the University of Chicago
Coauthors: Jack Hoadley & Laura Summer, Georgetown University
Katie Merrell, Social & Scientific Systems
Methods
• Analysis based on formularies Part D plans submitted to CMS
• Compared to the universe of drugs in the Formulary Reference File
Formulary Reference File
• Collapsed to the chemical entity level
‐ 4,825 NDCs become 1,107 drugs
• Weighted by plan enrollment
Weighted by plan enrollment
Average Share of Chemical Entities Listed on PDP Formularies, 2007‐2010
d
l
NOTE: Calculations are shares of all chemical entities listed on the Formulary Reference File provided by CMS. Ns are numbers of chemical entities
in the file for each year. Excludes MA-PDs, SNPs, and plans in US Territories.
Formulary Listing ≠ Coverage
• When a drug is on formulary, coverage may be restricted:
– High cost‐sharing tier
– Utilization management restrictions
Utilization management restrictions
• When a drug is off formulary, coverage may be possible:
– Formulary exception
y
p
– Temporary fill in transition coverage
A typical plan has four tiers
Median cost sharing for a month’s supply, 2010 (PDPs)
g
pp y
(
)
Generics
$7
Preferred Brands
Preferred Brands
$42
Non‐preferred Brands
$76
Specialty Drugs
30%
Share of Plans Using Various Tier Share
of Plans Using Various Tier
Structures, 2006‐2010 (for Non‐Specialty Drugs)
PDPs
1%
1%
<1%
<1%
MA-PDs
<1%
1%
3%
5%
1%
2%
NOTE: Calculations are percent of plans using selected tier structures for non-specialty tiers, as categorized by the authors. Results are weighted by
enrollment. Most plans also use a specialty tier. Excludes SNPs and plans in US Territories.
Median Copayments for Selected Tiers, d
f
l
d
2006 2010
2006‐2010
Non‐
preferred
f
d
Brands
Preferred
Brands
Generics
NOTE: Copayments are for a month’s supply. Calculations are weighted by enrollments. Excludes generic/brand plans, plans with coinsurance,
SNPs, and plans in the US Territories.
Median Share of On‐Formulary Drugs With Median
Share of On Formulary Drugs With
Utilization Management Applied, PDPs, 2007‐2010
NOTE:If a plan differentiates between different versions of a chemical entity, we use the status of the NDCs assigned to the lowest tier by that plan.
Calculations are weighted by enrollment; excludes SNPs and plans in the US Territories.
Median Share of Drugs With and Without Median
Share of Drugs With and Without
Formulary Restrictions, PDPs, 2007‐2010
87%
89%
89%
87%
NOTE: Calculations are shares of all chemical entities listed on the Formulary Reference File provided by CMS. Ns are numbers of chemical
entities in the file for each year. “Unrestricted” = placement on certain tiers (generic, brand, preferred brand) and absence of utilization
management restrictions (prior authorization, step therapy, quantity limits).
Share of Drugs With and Without Share
of Drugs With and Without
Restrictions in Top Plans, 2010
p
,
NOTE: Calculations are share of chemical entities. Totals may not add due to rounding. “Unrestricted” = placement on certain tiers (generic, brand, preferred
brand) and absence of utilization management restrictions (prior authorization, step therapy, quantity limits).
Variation in PDP Tier Assignments, Variation
in PDP Tier Assignments
Selected Cardiovascular Classes, 2010
NOTE: The percentage for the drug class is the unweighted average for the drugs in that class. The percentage for each drug represents the share
of PDPs, weighted by enrollment, for which the drug is on a particular tier. ARBs are angiotensin receptor blockers; ACE inhibitors are angiotensinconverting enzyme inhibitors.
Variation in PDP Tier Assignments, Selected Variation
in PDP Tier Assignments, Selected
Cardiovascular Drugs, 2010
Selected ARBs
Selected ACE Inhibitors
NOTE:The percentage for each drug represents the share of PDPs, weighted by enrollment, for which the drug is on a particular tier. ARBs are
angiotensin receptor blockers; ACE inhibitors are angiotensin-converting enzyme inhibitors.
Variation in PDP Tier Assignments, Variation
in PDP Tier Assignments
Selected Protected Classes, 2010
NOTE: The percentage for the drug class is the unweighted average for the drugs in that class. The percentage for each drug represents the share
of PDPs, weighted by enrollment, for which the drug is on a particular tier.
A Balancing Act
Access to
needed drugs
Current strategy:
R
Require
i plans
l
to
cover drugs in each
d
drug
class
l
Cost control
Current strategy:
Allow plans to
use prices and
UM to steer use
C
Concerns to watch for
t
t hf
• Complexity of tiering and UM may make it difficult for beneficiaries to determine which plan offers the best coverage for their situation.
situation
• The increased use of restrictions such as prior authorization and very high coinsurance deserve ongoing scrutiny.
• Funding
Funding for this research came from the for this research came from the
Medicare Payment Advisory Commission & the Kaiser Family Foundation
the Kaiser Family Foundation.
• More results on their websites:
http://www.medpac.gov/
http://kff org/medicare/med110909pkg cfm
http://kff.org/medicare/med110909pkg.cfm