How Does Drug Coverage Vary by Insurance Type? Analysis of Drug Formularies in the United States | Page 4

Published Online: April 21, 2014
Stephane A. Regnier, PhD, MBA
Compared with commercial plans, the level of on-patent drug coverage was consistently higher in employer, union, and PBM plans, and consistently lower in Medicare plans. One implication would be to reconsider coverage by Medicare plans for chronic therapeutic diseases with high costs. Patients enrolled with Medicaid (ie, the economically poorest segment of the population) had excellent on-patent drug coverage and good access to new technologies. Increased competition between plans does not reduce on-patent drug coverage for all therapeutic areas.

Take-Away Points

  • Insurance plans assign the drugs that they cover (ie, reimburse) to “tiers,” with the copay varying by tier (the lower the tier, the lower the copay).

  • For 3 drug classes in distinct therapeutic areas, access to on-patent drugs in the lowest copay tiers (1 and 2) was higher in employer, union, and pharmacy benefit management plans than in commercial plans. However, in Medicare plans, substantially fewer on-patent drugs were included in these tiers, which could create choice restrictions and thus compliance issues.

  • Medicare plans should reconsider access to on-patent drugs by tier for high-cost therapeutic areas without affordable alternatives.
Author Affiliation: The study reported in this paper was conducted as part of the author’s research at the University of Neuchâtel, Switzerland.

Author Affiliations: University of Neuchâtel, Switzerland. Novartis Vaccines and Diagnostics AG, Basel, Switzertland.

Source of Funding: No funding was received for this research; editorial assistance was funded by Novartis Vaccines & Diagnostics AG.

Author Disclosures: The author reports employment by Novartis Vaccines and Diagnostics AG (NVD). This paper represents the views of the author and should not be considered as representative of the views of NVD. Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; statistical analysis.

Address correspondence to: Stephane A. Régnier, St Alban Vorstadt 49A, CH-Basel 4052, Switzerland. E-mail: stephane.regnier@unine.ch.
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