The study published in Health Affairs illustrates a significant uptick in prescription drug restrictions within Medicare Part D plans from 2011 to 2020. Notably, there’s a substantial increase in drug exclusions from formularies and the implementation of prior authorization or step therapy requirements. Contrary to expectations, standalone prescription drug plans exhibit higher exclusion rates compared to Medicare Advantage plans. The findings emphasize the complex interplay between cost management and patient access to essential medications within the Medicare Part D program.
The introduction of the study in Health Affairs delves into the evolving landscape of prescription drug coverage within the Medicare Part D program. It highlights a notable escalation in prescription drug restrictions over the past decade, with increasing numbers of compounds being excluded from formularies or subjected to prior authorization or step therapy requirements. These trends raise questions about the accessibility of essential medications for Medicare beneficiaries and the role of cost management strategies in shaping prescription drug coverage within Part D plans.
Medicare Part D plans have significantly intensified their control over prescription drugs since 2011, as revealed by a study recently published in the March edition of Health Affairs.
According to the study’s findings, there has been a noticeable increase in restrictions imposed by Part D plans on prescription drugs. In 2011, approximately 20.4% of compounds were excluded from formularies, while 11.5% were subjected to prior authorization or step therapy requirements. By 2020, these figures had risen to 30.4% of compounds being excluded and 14% being placed under prior authorization or step therapy.
Interestingly, the study observed that standalone prescription drug plans exhibited a higher rate of drug exclusions from their formularies compared to Medicare Advantage plans. In 2020, standalone Part D plans excluded a significant 48.1% of brand-name compounds from their formularies, whereas MA-Part D plans excluded 41%.
Contrary to common perceptions, the study’s authors highlighted that Medicare Advantage plans, despite being integrated with medical coverage, did not employ more utilization management compared to standalone plans. The authors reasoned that MA-PD plans, which oversee both medical and prescription drug benefits, have a strong financial incentive to ensure access to expensive drugs. This is because such drugs can potentially prevent hospitalizations, reduce the need for outpatient care, or mitigate the necessity for costly medical procedures. Consequently, MA-PD plans are more inclined to prioritize providing access to these drugs to optimize patient outcomes while also managing costs effectively.
The study underscores the significant shift in prescription drug restrictions observed within Medicare Part D plans between 2011 and 2020. The findings reveal a nuanced relationship between cost containment efforts and patient access to essential medications, particularly concerning the differing approaches of standalone prescription drug plans and Medicare Advantage plans. Moving forward, policymakers and healthcare stakeholders must consider these evolving trends to ensure equitable access to prescription drugs for Medicare beneficiaries while effectively managing program costs.
