Medicare Part D Coverage Restrictions and Patient Cost-Sharing for Opioids Commonly Used for Cancer Pain, 2015-2021

Area of Science:

• Oncology
• Pain Management
• Health Policy

Background:

• Nationwide opioid dispensing has declined, raising concerns about pain management access for cancer patients.
• Restrictive insurance coverage may be a key factor limiting opioid access.
• Medicare Part D formulary changes are a critical area to examine for potential access barriers.

Purpose of the Study:

• To assess recent changes in Medicare Part D formulary designs for opioids commonly used in cancer-related pain.
• To evaluate the impact of these changes on patient access and out-of-pocket costs.

Main Methods:

• Analysis of Medicare Prescription Drug Plan (PDP) Formulary Files from 2015-2021.
• Estimation of prior authorization, quantity limits, and cost-sharing tier adoption for six common cancer pain opioids.
• Calculation of median and mean out-of-pocket costs for a 30-day supply.

Main Results:

• Prior authorization adoption increased to approximately 50% for two long-acting opioids.
• Quantity limits became more restrictive across all studied opioids.
• Out-of-pocket costs for four of six opioids doubled to quadrupled, with tier 3 or higher cost-sharing increasing significantly.

Conclusions:

• Medicare Part D coverage for cancer pain opioids has become substantially more restrictive.
• Significant increases in patient out-of-pocket costs raise concerns for pain management.
• Strategies are needed to exempt cancer-related pain from general opioid restrictions.