Health Reform WK-EDGE Part D plans generally include drugs commonly used by dual eligibles
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Thursday, July 23, 2020

Part D plans generally include drugs commonly used by dual eligibles

By Elena Eyber, J.D.

An OIG review found that the rate of Part D plan formularies’ inclusion of the 195 drugs commonly used by individuals who were eligible for both Medicare and Medicaid was high.

On average, Part D plan formularies included 97 percent of the 195 commonly used drugs and 75 percent of the commonly used drugs were included by all Part D plan formularies, according to a review by the HHS Office of Inspector General (OIG). The 2020 results were largely unchanged from the OIG’s findings for formularies reported in 2019 (OIG Report, No. OEI-05-20-00190, June 25, 2020).

Inclusion rates. The OIG found that the inclusion rates for the 195 drugs commonly used by dual eligibles were largely unchanged from the inclusion rates listed in the previous reports. Part D formularies included about the same high percentage of these commonly used drugs in 2020 as they did in 2019. Enrollment in plans that covered at least 90 percent of unique drugs increased slightly, with 95 percent of dual eligibles enrolled in the plans in 2020, compared to 94 percent of dual eligibles in 2019.

Utilization management tools. The OIG also found that the percentage of drugs to which plan formularies applied utilization management tools increased slightly between 2019 and 2020. On average, formularies applied utilization management tools to 29 percent of the unique drugs the OIG reviewed in 2020, an increase of 1 percentage point from 2019. Plans with premiums below the regional benchmarks used utilization management tools less frequently than all plans. Formularies of these plans used utilization management tools for 24 percent of their drugs.

Additional efforts. Lastly, the OIG found that because some variation existed in the inclusion by Part D plan formularies of the commonly used drugs and in Part D plan formularies’ application of utilization management tools to these drugs, some dual eligibles may need to make additional efforts to access the drugs they take. According to the OIG, these dual eligibles could appeal prescription drug coverage decisions, switch prescription drugs, or switch Part D plans.

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