The Medicare Prescription Drug Benefit (Part D) was intended to help Medicare beneficiaries afford their? medications and decrease the risk of patients skipping medications because of cost. However, policymakers? are concerned that variation among the formularies of the thousands of drug plans (n = 2,743) offered in? Medicare will make it impossible for providers to identify which drugs are covered. Studies show that Part D? formularies vary substantially in their coverage of the 152 most commonly used individual drugs, with some? plans covering less than 70% of these, while others cover over 95%. Thus, drugs that are covered for one? patient may not be covered for another, and providers must look up the formulary status for each drug for each? patient. This is impractical, so providers may often prescribe without knowing whether a drug is covered.? Prescribing drugs that create high out-of-pocket costs reduces patients? willingness to take their medicines,? especially for low income patients and those with multiple conditions.? Recent studies indicate that this issue is? has yet to be adequately addressed - 12% of Part D enrollees report leaving the pharmacy without a drug? because it was not covered or was too expensive [KFF 7/06], and 59% of providers say they rarely or never? check Part D formulary coverage prior to prescribing prescribing. Policy options include reducing formulary variation? through regulation or increasing providers? access to coverage information (e.g. using new technologies such? as listing widely covered drugs on a web site or e-prescribing). The optimal response depends on the nature? and severity of the problem. However, prior studies may have overstated the severity of the problem and the? difficulty of addressing it, as they have not been based on sufficient clinical framework of how prescribing? occurs. Providers think of drugs within treatment classes and often view drugs within a class as? interchangeable (e.g. ACE Inhibitors for hypertension). Thus, the important clinical question is not whether a? specific drug X is covered, but, ?Within each treatment class, is there one widely covered drug that providers? could routinely prescribe?? If so, one could greatly reduce the impact of formulary variation by alerting? providers to these widely covered drugs as ?first options? for prescribing. In addition, ?coverage? has been? defined in prior research without considering whether on-formulary drugs have high copays or require prior? authorizations, or whether coverage varies over time. We propose a secondary analysis of the CMS? Prescription Drug Plan Formulary and Pharmacy Network Files (?CMS Files?) to achieve these specific aims:? Aim 1 1. To determine the number of top 10 treatment classes that have one or more drug that is widely covered? (e.g., >= X% of plans at copays of <=$Y without prior authorization);? Aim 2 2. To determine formulary variability? and stability of widely covered drugs from January 1 1st st 2007 to January 1 1st st 2009 2009; We will use the National? Ambulatory Medical Care Survey to determine the top 10 classes used by seniors, and the CMS Files to? determine Part D plans in each state and the formulary coverage for these drugs.?
| Yazdany, Jinoos; Dudley, R Adams; Lin, Grace A et al. (2018) Out-of-Pocket Costs for Infliximab and Its Biosimilar for Rheumatoid Arthritis Under Medicare Part D. JAMA 320:931-933 |
| Yazdany, Jinoos; Dudley, R Adams; Chen, Randi et al. (2015) Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol 67:1474-80 |
