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Medicare Drug Program News
Best Bet to Find Drug Covered by Medicare Part D
Formulary is Go Generic
Study finds 90% of generics widely covered, just 6%
of brand-name
 June 19, 2007 – Millions of senior citizens have
taken a prescription from their doctor to the pharmacy, only to find the
drug is not covered by their Medicare Part D plan’s formulary. A new
study suggests the best bet for seniors is to ask their physician to
prescribe a generic - generic drugs were covered by 90 percent of
formularies studied.
“As a practicing doctor, I see this regularly,”
said one author, R. Adams Dudley, M.D., a Robert Wood Johnson Foundation
Investigator in Health Policy Research, University of California, San
Francisco.
“After I write out a prescription for a patient,
the patient or the pharmacy will call me back, asking for a prescription
that is covered. If doctors had this information in advance, we could
talk with our patients about their medication choices and determine
which option makes the best sense for them before writing a
prescription.”
Overall, less than half of drugs (45 percent) were
widely-covered. However, 7 of 8 treatment classes (excluding angiotensin
II receptor blockers, ARBs) had at least one widely covered drug. Nearly
all widely-covered drugs (94 percent) were generic drugs, and
three-fourths of generic drugs (73 percent) were widely-covered. On
average, generic drugs were covered by 90 percent of formularies.
Six percent of brand-name drugs were widely-
covered. Adopting the stricter requirement of coverage to include 95
percent or more of formularies at co-payments of $15 or less did not
change the study findings that 7 of 8 treatment classes had at least one
widely-covered drug.
This examination of Medicare Part D plans in
California and Hawaii reveals wide variations in drug formularies, but
indicates that for many classes of drugs, it is possible to find at
least one or more drug that is covered by nearly all Part D plans,
according to a study in the June 20 issue of Journal of the American
Medical Association.
“If doctors knew which drugs were most widely
covered by their Medicare plans, they could help patients get the drugs
they need, and often at a lower cost,” said study co-author Chien-Wen
Tseng, MD, a Robert Wood Johnson Foundation (RWJF) Generalist Physician
Faculty Scholar at the University of Hawaii, Honolulu, and a physician
investigator at the Pacific Health Research Institute.
Nearly 23 million of the 43.9 million eligible
Medicare beneficiaries have enrolled in the Medicare Part D prescription
drug benefit, according to background information in the article.
Because of the number and variety of plans, clinicians often find it
difficult to know which drugs are covered by Part D plan formularies.
Previous studies indicate that two-thirds of
clinicians say they lack familiarity with Part D formularies, and
three-fourths have been asked by pharmacies or patients to change a
prescription to a different drug so that it would be covered by the
patient’s plan.
The number of Part D plans is increasing, with
1,875 stand-alone prescription drug plans in 2007 compared with 1,429 in
2006. Many states have more than 50 Part D plans. “Wide formulary
variation can lead clinicians to inadvertently prescribe drugs that are
not covered by insurance or that require a high co-payment, increasing
patients’ financial burden and decreasing medication adherence,” the
authors write.
Tseng and colleagues conducted a study to determine
whether Part D formularies in California (the state with the most
Medicare beneficiaries) and Hawaii have at least one drug within each of
eight treatment classes for hypertension, hyperlipidemia, and depression
that can be identified for clinicians as “widely-covered” by the vast
majority of Part D plans.
The researchers used the Web site medicare.gov,
from March 1-April 15, 2006, to examine 72 California and 43 Hawaii Part
D formularies’ coverage of eight treatment classes:
● angiotensin-converting enzyme [ACE] inhibitors,
● angiotensin II receptor blockers [ARBs],
● beta-blockers,
● calcium channel blockers,
● loop diuretics,
● selective serotonin reuptake inhibitors,
● statins, and
● thiazide diuretics
They evaluated of how often these drugs were widely
covered (here defined as inclusion in 90 percent or more of formularies
at co-payments of $35 or less without prior authorization).
In an analyses of 72 formularies, the researchers
found that coverage for 75 specific drugs ranged from 7 percent to 100
percent of formularies and averaged 69 percent across all drugs.
Formulary coverage (percentage of formularies
covering each drug, averaged across all drugs within a class) was
highest for thiazide diuretics (90 percent) and beta-blockers (85
percent), followed by selective serotonin reuptake inhibitors (69
percent), calcium channel blockers (66 percent), ACE inhibitors (66
percent), statins (49 percent), and ARBs (39 percent).
“In this study to evaluate Medicare Part D plan
formulary variation, the coverage of individual drugs varied
extensively, indicating the potential difficulties that clinicians can
face in knowing which drugs are covered or are more affordable,” the
authors write.
“… a potential way to address formulary variation
would be to identify, within a class, which drugs are widely covered and
generally more affordable for clinicians to consider. This could
substantially reduce clinicians’ administrative burden from formulary
variation and lower the risk that Medicare beneficiaries are
inadvertently prescribed noncovered or higher cost-sharing drugs.”
“Clinicians should also be alerted to those classes
with no widely covered drugs, from which they should not prescribe
without first checking formulary coverage.
“For example, the maximum coverage for any single
ARB was 81 percent of formularies. If this type of coverage information
were made available in interactive fashion via a Web site, personal
digital assistant–based tool, or e-prescribing software, clinicians
could use this knowledge in the clinical encounter during collaborative
decision making on selecting medications.”
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