Variability of COPD inhaler coverage in Medicare Part D

Area of Science:

• Health Services Research
• Pharmaceutical Policy
• Respiratory Medicine

Background:

• Medicare Part D offers Stand-alone Prescription Drug Plans (S-PDPs) and Medicare Advantage Prescription Drug (MA-PD) plans, each with distinct incentives for medication coverage.
• Coverage of inhalers, crucial for managing chronic obstructive pulmonary disease (COPD) exacerbations, may differ between these plan types.
• Understanding these differences is vital for Medicare beneficiaries and the program's financial health.

Purpose of the Study:

• To compare the formulary coverage of guideline-recommended COPD inhalers between S-PDPs and MA-PD plans.
• To analyze differences in utilization management tools like prior authorization and step therapy, and cost-sharing mechanisms such as coinsurance.

Main Methods:

• A cross-sectional analysis was conducted on the formularies of all S-PDPs and MA-PD plans available in 2017.
• Coverage of inhalers across six therapeutic categories, based on the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, was assessed.
• Prior authorization, step therapy, and coinsurance requirements were compared between S-PDPs and MA-PD plans.

Main Results:

• All plans covered at least one inhaler per GOLD therapeutic category, excluding certain combination inhalers.
• S-PDPs more frequently imposed coinsurance across all categories compared to MA-PD plans.
• MA-PD plans utilized prior authorization more often for 3 of the 6 categories, while S-PDPs had significantly higher coinsurance rates for mild, moderate, and severe COPD inhalers.

Conclusions:

• Medicare Part D S-PDPs exhibit a greater propensity to require coinsurance for outpatient COPD inhalers, especially for those treating severe disease.
• These coverage disparities likely stem from differing financial incentives inherent to S-PDPs and MA-PDs.
• These findings are crucial for healthcare providers and policymakers focused on optimizing outpatient COPD management within the Medicare framework.