Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E Montview Blvd, Mail Stop C238, Aurora, CO 80045. Email:
Am J Manag Care. 2022 Jul 1;28(7):e255-e262. doi: 10.37765/ajmc.2022.89184.
To examine the use of step therapy, prior authorization, and Part D formulary exclusion by 4 large Medicare Advantage (MA) insurers to manage 20 physician-administered drugs with the highest total Medicare expenditures (top 20 drugs).
We collected data for United Healthcare, CVS/Aetna, Humana, and Kaiser plans to create a database of 2020 Part B coverage restrictions and conducted a retrospective analysis of 2018-2020 Part D formularies.
For each insurer, we calculated the number of top 20 physician-administered drugs subject to prior authorization and step therapy. For physician-administered drugs for which there were no similar or interchangeable alternatives, we examined which insurers required prior authorization or step therapy. Finally, we examined whether insurers restricted access to physician-administered drugs by reducing coverage on Part D formularies.
Of the top 20 physician-administered drugs, 17 were subject to prior authorization and 10 were subject to step therapy by at least 1 insurer. For 5 physician-administered drugs without a similar or interchangeable alternative, none were subject to step therapy and all were subject to prior authorization by at least 1 insurer. Across the 4 insurers, 16 physician-administered drugs were covered on all or some of the Part D formularies in 2018, which decreased to 6 in 2020.
Four large MA insurers managed access to expensive physician-administered drugs with a combination of prior authorization, step therapy, and Part D formulary design. When a low-cost alternative exists, these tools can help reduce wasteful spending, but the administrative barriers may also reduce access.
研究 4 家大型医疗保险优势计划（MA）保险公司如何使用阶梯疗法、事先授权和 Part D 处方集排除来管理 20 种总医疗保险支出最高的医师管理药物（前 20 种药物）。
我们收集了 United Healthcare、CVS/Aetna、Humana 和 Kaiser 计划的数据，创建了 2020 年 Part B 覆盖限制数据库，并对 2018-2020 年 Part D 处方集进行了回顾性分析。
对于每个保险公司，我们计算了受事先授权和阶梯疗法限制的前 20 种医师管理药物的数量。对于没有类似或可互换替代品的医师管理药物，我们检查了哪些保险公司需要事先授权或阶梯疗法。最后，我们检查了保险公司是否通过减少 Part D 处方集的覆盖范围来限制医师管理药物的使用。
在前 20 种医师管理药物中，有 17 种受到至少 1 家保险公司的事先授权限制，有 10 种受到阶梯疗法限制。对于 5 种没有类似或可互换替代品的医师管理药物，没有一种受到阶梯疗法限制，所有药物都受到至少 1 家保险公司的事先授权限制。在这 4 家保险公司中，2018 年有 16 种医师管理药物在所有或部分 Part D 处方集中得到覆盖，而到 2020 年则减少到 6 种。
4 家大型 MA 保险公司通过事先授权、阶梯疗法和 Part D 处方集设计相结合来管理昂贵的医师管理药物的使用。当存在低成本替代品时，这些工具可以帮助减少浪费性支出，但行政障碍也可能会降低可及性。
