Abstract
During congressional debate over the Medicare Part D prescription drug benefit, much attention was focused on nominal benefit design. Relatively little attention was paid to details about how plans would operate, such as the design of drug formularies. Yet, formularies will be important tools for controlling costs, and may be as important as nominal benefit design in determining enrollees’ access to medications and out-of-pocket costs. We describe Part D plan incentives and how they may influence formulary design, and then provide recommendations for Part D formulary implementation. We encourage the Centers for Medicare & Medicaid Services (CMS) to develop standardized tools to provide physicians and patients with up-to-date and easily accessible information about covered drugs on each plan’s formulary (perhaps via a central website) and a national set of easy-to-follow procedures for reconsideration and appeals. Such efforts should reduce administrative burden and better allow physicians to help patients obtain needed medications.
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References
Huskamp HA, Keating NL. The New Medicare Drug Benefit: Potential Effects of Pharmacy Management Tools on Access to Medications. Washington, DC: Accessed at http://www.kff.org/medicare/7120a.cfm. Accessed July 26, 2004.
Department of Health and Human Services. Medicare Modernization Update: Regulation and Notices. Available at: http://www.cms.hhs.gov/mmv/regulations/. Accessed May 9, 2005.
Cutler DM, Zeckhauser RJ. The anatomy of health insurance. In: Culyer AJ, Newhouse JP, eds. Handbook of Health Economics, Vol. 1A. New York: Elsevier; 2000:564–643.
Ellis RP. The effect of prior-year health expenditures on health coverage plan choice. Adv Health Econ Health Services Res. 1985;6:149–70.
Pauly MV, Zeng Y. Adverse selection and the challenges to stand-alone prescription drug insurance. National Bureau of Economic Research Working Paper 9919, Cambridge, Mass, August 2003.
Stuart BC, Ahern F, Rabatin V, Johnson A. Patterns of outpatient prescription drug use among the elderly: evidence from the PACE program. Health Care Financ Rev. 1991;12:61–72.
Hogan C. MCBS-based study of prescription drug coverage linked to Medicare claims. Report delivered to Department of Health and Human Services, Office of the Secretary, Assistant Secretary for Planning and Evaluation under Number BPA-OS-00-0203-A, Washington, DC, October 25, 2000.
Wrobel MV, Doshi J, Stuart BC, Briesacher B. Predictability of prescription drug expenditures for medicare beneficiaries. Health Care Financ Rev. 2003–2004;25:37–46.
Zhao Y, Ash A, Ellis R, et al. Predicting pharmacy costs and other medical costs using diagnoses and drug claims. Med Care. 2005;43:34–43.
Schneeweiss S, Walker AM, Glynn RJ, Maclure M, Dormuth C, Soumerai SB. Outcomes of reference pricing for angiotensin-converting-enzyme inhibitors. N Engl J Med. 2002;346:822–9.
Schneeweiss S, Soumerai SB, Maclure M, Dormuth C, Walker AM, Glynn RJ. Clinical and economic consequences of reference pricing for dihydropyridine calcium channel blockers. Clin Pharmacol Ther. 2003;74:388–400.
Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, Frank RG. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med. 2004;349:2224–32.
Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291:2344–50.
Brown AS, Bakker-Arkema RG, Yellen L, et al. Treating patients with documented atherosclerosis to National Cholesterol Education Program-recommended low-density lipoprotein cholesterol goals with atorvastatin, fluvastatin, lovastatin and simvastatin. J Am Coll Cardiol. 1998;32:665–72.
Glassman PA, Good CB, Kelley ME, et al. Physician perceptions of a national formulary. Am J Manage Care. 2001;7:241–51.
Glassman PA, Tanielian T, Harris K, et al. Provider perceptions of pharmacy management: lessons from the military health system. Med Care. 2004;42:361–6.
Landon BE, Reschovsky JD, Blumenthal D. Physicians’ views of formularies: implications for Medicare drug benefit design. Health Aff (Millwood). 2004;23:218–26.
Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient-physician communication about out-of-pocket costs. J Gen Intern Med. 2004;19:856–60.
Medicare Prescription Drug Improvement and Modernization Act of 2003. Available at: http://cms.hhs.gov/medicarereform/MMAact FullText.pdf. Accessed May 9, 2005.
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NLK received grant funding from Novartis in December 2004.
This work was supported by the Henry J. Kaiser Family Foundation. We are grateful to Tricia Neuman, Gary Claxton, Barbara McNeil, and John Ayanian for many helpful comments on an earlier draft.
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Huskamp, H.A., Keating, N.L. The new medicare drug benefit: Formularies and their potential effects on access to medications. J GEN INTERN MED 20, 662–665 (2005). https://doi.org/10.1007/s11606-005-0115-3
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DOI: https://doi.org/10.1007/s11606-005-0115-3