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Access to Cancer Drugs in Medicare Part D

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Presentation on theme: "Access to Cancer Drugs in Medicare Part D"— Presentation transcript:

1 Access to Cancer Drugs in Medicare Part D
October 16, 2006 Jennifer Bowman Avalere Health LLC

2 Study Published in Health Affairs, September / October 2006
Copyrighted and published by Project HOPE / Health Affairs as J. Bowman, A. Rousseau, D. Silk and C. Harrison, “Access to Cancer Drugs in Medicare Part D: Formulary Placement and Beneficiary Cost-Sharing in 2006,” Health Affairs 25 (5): 1240 – 1248, The published article is archived and available online at

3 Background 700,000 Medicare beneficiaries diagnosed with cancer annually; Medicare spending of $7.3 billion in 2004 Medicare drug benefit expands coverage to previously non-covered oral and self-injectible cancer drugs CMS reviews Part D plan formularies to ensure non-discrimination CMS required coverage of “all or substantially all” anti-neoplastics in 2006

4 Objectives Analyze Medicare Part D plan formularies
Assess variation in coverage and cost-sharing for oral and self-injectible cancer drugs Explore implications for beneficiary access

5 Methods Defined universe of drugs FDA-approved to treat cancer
Included oral, subcutaneous injection, topical, elixir and suspension forms Excluded infused chemotherapy drugs, cancer supportive care, and oral cancer drugs covered by Medicare Part B Coded drugs as brand-name or generic Analyzed 1 February 2006 extract of the CMS Prescription Drug Plan Formulary and Pharmacy Network Files Examined data on plan characteristics, formulary characteristics and copayments or coinsurance

6 Coverage of Cancer Drugs on Part D Plans' Formularies
Type of Plan PDPs (n=1,446) Regional MA-PD plans (n=51) Local MA-PD plans (n=1,496) Percent of Cancer Drugs On Formulary All Drugs 75% 85% Brand 70 82 71 Generic 99 100 98 Percent of Cancer Drugs Covered with Prior Authorization 10 3 12 4 11 1 Percent of Cancer Drugs Covered with Quantity Limit 5 2 Source: Authors' analysis of CMS Prescription Drug Plan Formulary and Pharmacy Network Files, February 1, 2006 data transfer.

7 Formulary Presence and Tiers: Brand-Name Cancer Drugs
PDPs (N=1,446 Plans) MA-PDs* (N=1,547 Plans) Brand Name Percent On-Formulary Mean Tier Ceenu 100% 2.2 Thioguanine 2.1 2.3 Targretin 2.8 2.7 Tarceva 3.1 Aromasin 2.4 99.9% Hexalen Femara Lysodren Teslac 2.5 Leukeran Casodex 99.8% Emcyt Matulane 99.7% Arimidex 99.1% Gleevec 98.8% * Combined Local and Regional MA Plans Source: Authors' analysis of CMS Prescription Drug Plan Formulary and Pharmacy Network Files, February 1, 2006 data transfer.

8 Formulary Presence and Tiers: Generic Cancer Drugs
PDPs (N=1,446 Plans) MA-PDs* (N=1,547 Plans) Ingredient Name Percent On-Formulary Mean Tier Prednisone 100% 1.0 Dexamethasone 99.9% Flutamide 1.2 Tamoxifen Citrate 1.1 99.8% Megestrol Acetate 99.5% * Combined Local and Regional MA Plans Source: Authors' analysis of CMS Prescription Drug Plan Formulary and Pharmacy Network Files, February 1, 2006 data transfer.

9 Formulary Presence: Ten Least-Often Covered Cancer Drugs
Percent On-Formulary Ingredient Name Brand Name PDPs (N=1,446 Plans) MA-PDs* (N=1,547 Plans) Methyltestosterone Virilon 0% 4% Flutamide Eulexin 17% 19% Hydroxyurea Hydrea 16% 27% Dexamethasone Decadron 24% Toremifene Fareston 22% 30% Mercaptopurine Purinethol 23% 32% Tamoxifen Nolvadex 29% 37% Megestrol acetate Megace 38% Android 36% 47% Testred 42% 45% * Combined Local and Regional MA Plans Source: Authors' analysis of CMS Prescription Drug Plan Formulary and Pharmacy Network Files, February 1, 2006 data transfer.

10 Cost-Sharing: Brand-Name Cancer Drugs
PDPs (N=1,446 Plans) MA-PDs* (N=1,547 Plans) Brand Name % of Plans Using Copay Median Copay Ceenu 84% $28 82% $30 Thioguanine 86% 78% $29 Targretin 56% 64% $35 Tarceva 43% $40 50% Aromasin Hexalen 61% 67% Femara Lysodren Teslac 70% 71% Leukeran $27 Casodex Emcyt 80% Gleevec 42% 49% Matulane 77% Arimidex * Combined Local and Regional MA Plans Source: Authors' analysis of CMS Prescription Drug Plan Formulary and Pharmacy Network Files, February 1, 2006 data transfer.

11 Cost-Sharing: Generic Cancer Drugs
PDPs (N=1,446 Plans) MA-PDs* (N=1,547 Plans) Ingredient Name % of Plans Using Copay Median Copay Prednisone 91% $5 84% Dexamethasone 87% Flutamide 82% Tamoxifen Citrate Megestrol Acetate * Combined Local and Regional MA Plans Source: Authors' analysis of CMS Prescription Drug Plan Formulary and Pharmacy Network Files, February 1, 2006 data transfer.

12 Implications Expanded access to cancer drugs under Medicare Part D
“All or substantially all” policy Prior authorization applied more often to brand-name drugs than generics Copayments more often than coinsurance; $5 to $40 copayments Patient out-of-pocket cost is generally higher with coinsurance Part D coverage gap may have significant impact for Medicare beneficiaries with cancer

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