Access to Pharmaceuticals Under Part D
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1 Access to Pharmaceuticals Under Part D Jennifer Bowman Director, Medicare Practice Avalere Health LLC October 16, 2006 Avalere Health LLC The intersection of business strategy and public policy
2 Competing Goals: Access and Cost Control CMS seeks to implement a strategy to ensure that formularies and pharmacy benefit management are consistent with effective practices in drug benefit management today. - CMS Strategy for Affordable Access to Comprehensive Drug Coverage 2006 Cost Control Access Page 2
3 Plan Sponsors Took Advantage of Flexibility in Statute and Regulations 9% of PDPs and 13% of MA-PD plans offer the standard benefit 66% of PDPs and 76% of MA-PD plans offer a $0 or reduced deductible 15% of PDPs and 24% of MA-PD plans offer coverage in the gap 99% of Part D plans use multiple cost-sharing tiers 4-tier benefit structures are most common 48% of PDPs and 56% of MA-PD plans use a specialty tier Formulary size varies from 1,017 to 5,398 for PDPs and 756 to 8,461 for MA-PD plans Plans generally complied with the all or substantially all mandate for 6 protected classes, but 5 of these classes are still subject to prior authorization or step therapy restrictions It is as yet unclear how stringently plans are applying their appeals and exceptions criteria Page 3
4 Coverage Gap in The Press Medicare: Americans falling into cost gap - Jonathan Ellis, August 3, 2006 Health Costs: Dodge the Doughnut Hole - Laurie McGinley, August 27, 2006 More patients fall into a hole in drug benefit - Richard Wolf, August 26, 2006 Medicare drug coverage gap leaves many seniors broke, or skipping medication - Monica Hatcher, August 6, 2006 Medicare Beneficiaries Confused and Angry Over Gap in Drug Coverage - Robert Pear, July 30, 2006 Millions of Seniors Facing Medicare Doughnut Hole - Christopher Lee and Susan Levine, September 25, 2006 Page 4
5 Most PDP Enrollees Have No Gap Coverage Percent of Enrollment in PDPs Offering Coverage in the Gap No Coverage 94.0% Generics Only Coverage 2.9% Generic & Brand Coverage 3.1% Most PDPs did not offer coverage in the gap; plans that did had higher premiums Example: Humana Standard ($1.87 $17.06) Humana Complete ($ $73.17) N = 15.5 million Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Plan benefit and formulary design data from April Enrollment data from July Analysis excludes lives in PDPs with fewer than 10 enrollees, lives in employer/union only Part D plans, and lives in the U.S. territories. Page 5
6 Size of Coverage Gap Increases Dramatically Over Time Drug Spending ($) Doughnut Hole in 2006 = $2,850 Doughnut Hole in 2013 = $5, Year * Assumes that growth in drug costs significantly exceeds CPI. Source: 2006 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, Table V.C2., p Page 6
7 Plans With Gap Coverage Have Larger Formularies ,516 Brand Generic Average # of Drugs ,060 1,027 1,014 1, ,278 1,048 1,080 1,188 0 No Coverage Generic Only Generic + Brand No Coverage Generic Only Generic + Brand N= 1208 N= 188 N= 33 N= 1142 N= 292 N= 74 PDPs MA-PD Plans Source: Avalere Health analysis using DataFrame, a proprietary database of Medicare Part D plan features. Data from February Page 7
8 On Average, Part D Plans Cover 2,263 Drugs 2400 On average, MA-PD plans cover slightly more drugs than PDPs. For both plan types, branded products make up over half of the formulary. 2,166 2, Generic Branded PDPs MA-PD Plans Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from July 27, Page 8
9 Plans With Robust Formularies Captured a Significant Portion of PDP Lives Number of Enrollees (millions) WellCare, PacifiCare, and SilverScript offer formularies with <1500 drugs 3.7 Unicare, Medco, and MEMBERHEALTH s plan offerings have between 1501 and 2000 drugs on formulary United and Humana s plan offerings have over 3,500 drugs on formulary < >4000 Number of Drugs on Plans' Formularies Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Plan benefit and formulary design data from April Enrollment data from July Analysis excludes lives in PDPs with fewer than 10 enrollees, lives in employer/union only Part D plans, and lives in the U.S. territories. Page 9
10 Utilization Management in Part D Page 10
11 PDPs Use Utilization Management Techniques At Higher Rates than MA-PD Plans Do Total Drugs Covered Prior Authorization PDPs Number of Percentage of Drugs Drugs % 10% Number of Drugs MA-PD Plans Percentage of Drugs 100% 8% At least 11% of drugs are subject to a utilization management tool in PDPs Step therapy is used sparingly by both PDPs and MA-PD plans Quantity Limits % 175 7% Step Therapy 12 <1% 14 <1% Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from July 27, Page 11
12 4-Tier Structures Most Common Among Part D Plans More Than Is Typical in Commercial Plan Designs Number of Tiers in Plan 1 Tier 2 Tiers 3 Tiers Number of Plans PDPs Percentage of Plans <1% 8% 37% Number of Plans MA-PD Plans Percentage of Plans 2% 17% 15% Four tier structures most common among Part D plans PDPs have between 1 and 6 tiers Average 3.6 tiers 4 Tiers 5 Tiers 6 Tiers 7 Tiers % 19% <1% 0% % 13% <1% <1% MA-PD plans have up to 8 tiers Average 3.6 tiers 8 Tiers 0 0% 4 <1% Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from July 27, Page 12
13 Most Beneficiaries in PDPs Are in Plans With Four or More Tiers N = 1429 N = 15.5 million 5 tier, 19% 5 tier, 9% 4 tier, 35% 4 tier, 65% 3 tier, 37% 3 tier, 22% 2 tier, 8% 1 tier, 1% 2 tier, 3% 1 tier, 1% Percent of PDPs With Different Tiering Structures Percent of Enrollment in PDPs With Different Tiering Structures Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Plan benefit and formulary design data from April Enrollment data from July Analysis excludes lives in PDPs with fewer than 10 enrollees, lives in employer/union only Part D plans, and lives in the U.S. territories. Page 13
14 Part D Plans Tend to Have Larger Spreads Between Cost- Sharing Requirements on the First and Second Tiers PDPs MA-PD Plans Commercial Plans $58 Tier 3 $5 Tier 1 $20 Tier 2 25% Tier 3 $0 Tier 1 $28 Tier 2 25% Tier 4 $10 Tier 1 $22 Tier 2 $35 Tier 3 Most common costsharing for 3-tier PDPs Most common costsharing for 4-tier MA-PD plans Average cost-sharing in employersponsored plans* Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from July 27, * Kaiser Family Foundation. Employer Health Benefits Annual Survey. Page 14
15 Average Specialty Tier Holds 4-6% of Covered Drugs Plans typically place fewer than 200 drugs on specialty tier» PDPs place 4% of covered drugs» MA-PD plans place 6% of covered drugs» But, a few plans place drugs on specialty tier at over twice this rate Treatment of Drugs on Specialty Tiers Drugs on Specialty Tier 120 Drugs with PA Drugs without PA Average number of drugs on specialty tier = 100 Drugs on specialty tiers have higher cost-sharing and PDPs MA-PD Plans higher rates of prior authorization relative to the rest of plans formularies An average of 8 specialty tier drugs are subject to quantity limits on PDP formularies, and 13 on MA-PD plan formularies. Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from February Page 15
16 20 Most Common Drugs Found on Specialty Tiers Cancer Neupogen Tarceva Intron-A Gleevec Sandostatin Multiple Sclerosis Avonex Copaxone Betaseron Rheumatoid Arthritis Humira Remicade Enbrel Anemia Procrit Aranesp Hep C Peg-Intron Pegasys Intron-A Other Fabrazyme Fuzeon Cerezyme Tracleer These drugs are on over 70% of specialty tiers Many drugs found on specialty tiers are eligible for Part B coverage in certain situations Very few drugs found on specialty tiers are generics Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from February Page 16
17 Cost-Sharing on Specialty Tiers Typically Is High % Almost all plans use percentage coinsurance on specialty tier Number of Plans < $100 30% $100 20% Specialty Tier Cost-Sharing N = % Fewer than 5% of plans use copays MA-PD plans are more likely to use copays Most plans without specialty tiers use flat copays on every tier, with highest tier at $25-60 Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from February Page 17
18 Coverage of the Protected Classes in Part D On Formulary % with PA % with QL Most Common Cost-sharing HIV/AIDS 100% 0% 4% $20-30 Antidepressants 76% 3% 37% $20-30 Antipsychotics 100% 15% 37% $20-30 Antineoplastics 75% 10% 4% $20-30 Source: Avalere Health analysis using DataFrame TM, a proprietary database of Medicare Part D plan features. Data from April Page 18
19 Cost-Sharing Case Study: Cancer Wide variation in out-of-pocket spending, depending on type of cancer diagnosis and drug regimen prescribed Part D low income subsidies are highly beneficial for those who qualify Part B supplemental coverage important protection does not exist for Part D out-of-pocket costs Since beneficiaries most likely are not choosing plans based on expectation of cancer diagnosis, they may be stuck with high cost-sharing if they are diagnosed mid-year and are enrolled in a plan without gap coverage Page 19
20 Access in Part D: 2007 and Beyond Lower base beneficiary premium in 2007, but premium increases expected over time Plan participation relatively stable in 2007 but market consolidation expected in future Diminishing variability in benefit design Increasing utilization management Continued importance of generics Increasing cost-sharing Feedback loop between commercial and Part D benefit structures Page 20
21 Access Questions For The Future Did beneficiaries choose the optimal plan for them? What effect will the November 2006 and November 2008 elections have on the stability of Part D? What effect is Part D having on access to drugs for duals, LTC residents, and other Medicare subpopulations? Page 21
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