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A new study from University of Southern California (USC) researchers shows that Medicare Part D plans have been increasingly restricting access to some prescription drugs through the years. Plans have used prior authorization, step therapy, and formulary restrictions to curb beneficiaries’ ability to take certain important prescriptions. The study covered 10 years, from 2011 to 2020, and showed plan adoption of each of these utilization management practices steadily gaining traction.
Plans can exclude some drugs from their formularies entirely, meaning enrollees either must pay out of pocket or try to get an exception by submitting an appeal to the plan. In 2011, plans excluded 20.4% of drugs. By 2020, that number was up to 30.4%, with an even higher 44.7% for brand-name drugs.
Even if drugs are on the formulary, plans can limit access. For example, prior authorization requires prescribers to get plan permission before it will cover a drug, and step therapy requires patients to use one or more other drugs before gaining access to the prescribed drug. In 2011, plans subjected 11.5% of drugs to prior authorization or step-therapy restrictions. By 2020, that number had reached 14%, with a higher 23.7% for brand-name drugs.
[EXTERNAL LINK] - Study Shows Part D Plans Ratcheting Up Restrictions on Coverage - Medicare Rights Center
Plans can exclude some drugs from their formularies entirely, meaning enrollees either must pay out of pocket or try to get an exception by submitting an appeal to the plan. In 2011, plans excluded 20.4% of drugs. By 2020, that number was up to 30.4%, with an even higher 44.7% for brand-name drugs.
Even if drugs are on the formulary, plans can limit access. For example, prior authorization requires prescribers to get plan permission before it will cover a drug, and step therapy requires patients to use one or more other drugs before gaining access to the prescribed drug. In 2011, plans subjected 11.5% of drugs to prior authorization or step-therapy restrictions. By 2020, that number had reached 14%, with a higher 23.7% for brand-name drugs.
[EXTERNAL LINK] - Study Shows Part D Plans Ratcheting Up Restrictions on Coverage - Medicare Rights Center