Health Insurance Medicare Part D Pharmaceuticals

Part D prior authorization and cost sharing rise for MS treatments

If you have multiple sclerosis, effective disease modifying therapies (DMTs), can help to reduce relapse rates and slow disease progression. That is, if you can get access to them. A paper by Hartung et al. (2019) found the following when examining 2007-2016 Prescription Drug Plan Formulary files concerning DMT coverage among Part D plans:

Among therapies available throughout the study period, the rate of prior authorization use increased from 61–66 percent of plans to 84–90 percent. The share of plans with at least one therapy available without limitations declined from 39 percent to 17 percent. The projected cumulative out-of-pocket spending for 2019 was $6,894… Step-therapy edits were used infrequently.

These DMTs are expensive. However, health insurance and having “coverage” for a treatment may mean different things when prior authorization and high cost sharing restricts patient access to these therapies.

1 Comment

  1. When the annual cost of a chronic drug is 30 x my annual fee as a concierge physician, it is to be expected that every tool in the book will be utilized to obstruct the patient and physician. The incentive for new drugs is not something we want to obstruct, but we need to amortize the return over time. Otherwise, we cannot expect any kind of stability of costs while we also hope to advance new diagnostics and therapeutics. With news that quality is a problem in generics, that price fixing is prevalent, and that shortages persist; it is time to realize that a price regulated, brand vs brand open-formulary provides the only true structure that will allow patient-physician autonomy, eliminate the administrative waste (by destroying its whole basis), control costs, and allow for continued improvement in our tools of care.

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