Managed Care

PDP drug restrictions block comparison shopping

A review of 169 commonly used drugs covered by Medicare Prescription Drug Plans (PDPs) reveals that only 4 of the 10 largest plans by enrollment have all of those 169 drugs on formulary, according to a study conducted by the Henry J. Kaiser Family Foundation. Furthermore, even those four PDPs limit access, because patients have unrestricted access to less than 60 percent of the drugs. Utilization management, quantity limits, and step therapy are examples of restrictions that these plans use to limit access.

Elizabeth Hargrave, a senior research scientist at the National Opinion Research Center at the University of Chicago and coauthor of the review, says that “plans implement very different strategies to manage the number of drugs they cover and place restrictions on how easy it is to access them, even when the drugs are covered on formulary. Short of having claims data, it’s very hard to drill down and measure whether beneficiaries have access to the drugs they need,” says Hargrave.

“Overall, it is difficult to get an apples-to-apples comparison of which plan formularies are most generous because of the different approaches plans have taken,” says Hargrave.

Unrestricted formulary coverage of 169 sample drugs

Prescription Pathway Bronze covers just 127 (75 percent) of the 169 drugs that were reviewed, but applies utilization management rules to only 3 percent of them. In contrast, Humana’s three plans list all 169 sample drugs on formulary, but 60 percent carry utilization management restrictions. The use of these restrictions may make access to covered drugs more difficult for enrollees.

Source: Hoadley, et al. Analysis of CMS data on stand-alone PDPs offered by national organizations, 2008. Prepared for the Kaiser Family Foundation.

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