SummaryAn Avalere analysis found that Medicare prescription drug plans (PDPs) had lower levels of coverage and fewer medicines on less expensive formulary tiers than commercial health insurance plans, potentially impacting patients' access to anticonvulsants.
This analysis measured access to anticonvulsants by each drug’s presence on the formulary, level of cost-sharing, and utilization management techniques.
Overall, the Avalere study concluded that:
Commercial plans had higher levels of coverage of anticonvulsants on formularies than PDPs, including more coverage of brand-name and extended release products. This research was conducted by Avalere Health and funded by UCB, Inc. Avalere maintained full editorial control and the conclusions expressed here are solely those of the study’s authors.
- Commercial plans placed more covered anticonvulsants on lower tiers than PDPs.
- Cost-sharing on tiers one and two were higher for commercial plans than PDPs. For tiers three and four, cost-sharing was nearly level among both sets.
- For a medicine placed on a specialty tier, the difference in cost-sharing between coinsurance and a fixed copayment could be substantial. According to a recent report by the Government Accountability Office, the median negotiated price of all specialty tier-eligible drugs in 2007 was $1,100. Under a commercial plan with a $1,100 specialty drug on the highest tier, a patient would pay $79 a month on average. In contrast, a Medicare beneficiary enrolled in a PDP would pay 30 percent, or $330 a month, on average for the same medicine.
- Usage of utilization management techniques was fairly similar among PDPs and commercial plans.