The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review

Park, Yujin; Raza, Syed Atif; George, Aneesh Thomas; Agrawal, R.; Ko, John J.

doi:10.18553/jmcp.2017.23.8.893

Cited by 46 publications

(47 citation statements)

References 45 publications

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“…[19][20][21][22] Although formulary restrictions are typically implemented to manage spending and drug utilization, 14 they can negatively impact medication fills and adherence. 23,24 Our results may provide context to the findings from a U.S. survey of transgender individuals, in which 25% of respondents reported being denied insurance coverage for hormone therapies. 3 These access barriers may result in higher OOP costs and lack of adherence to HT.…”

Section: Discussionsupporting

confidence: 56%

Medicare Prescription Drug Plan Coverage of Hormone Therapies Used by Transgender Individuals

et al. 2020

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Purpose: Although pharmacologic hormone therapy represents one of the mainstays of gender-affirming therapy for transgender individuals, there are many access barriers for these therapies, including insurance coverage of these drugs. The purpose of this study was to examine Medicare coverage of hormone therapies used by transgender individuals. Methods: Using Centers for Medicare and Medicaid Services prescription drug plan formulary files, we determined plan coverage, coverage restrictions, and out-of-pocket (OOP) costs for all 10 drugs recommended in the 2009 and 2017 Endocrine Society treatment guidelines for transgender patients. Results: For masculinizing therapies, the proportion of plans providing unrestricted coverage ranged from 22% to 79% in 2010 and from 5% to 75% in 2018. For feminizing therapies, the proportion providing unrestricted coverage ranged from 24% to 100% in 2010 and from 13% to 100% in 2018.

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Section: Discussionsupporting

confidence: 56%

Medicare Prescription Drug Plan Coverage of Hormone Therapies Used by Transgender Individuals

et al. 2020

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“…Research addressing other aspects of health systems and insurers has shown that benefit design at this level, such as the use of prescription drug formularies, step therapy, and patient costsharing, can affect receipt of treatment and treatment adherence (49)(50)(51)(52)(53)(54). It is likely that health care system features, such as breadth and depth of provider networks, benefit design, routine use of EHR functionality in quality improvement, and financial assistance infrastructure, are associated with patient financial hardship, and these areas are important research gaps.…”

Section: Health Care System-level Risk Factors For Medical Financial mentioning

confidence: 99%

Medical Financial Hardship among Cancer Survivors in the United States: What Do We Know? What Do We Need to Know?

Yabroff

Zhao

Zheng

et al. 2018

Cancer Epidemiology, Biomarkers &Amp; Prevention

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Rising costs of cancer care have led to increased concerns about medical financial hardship for cancer survivors and their families in the United States. In this commentary, we provide an overview of research describing medical financial hardship and introduce a conceptual framework for identifying risk factors and research gaps at the patient and family, provider and care team, health care system, employer, and state and national policy levels. We then use this framework to highlight measurement and data infrastructure gaps related to hardship, summarize existing interventions to minimize hardship, and identify opportunities for future intervention efforts.

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“…Because prior authorization has been shown to reduce access to medications, some public and private programs have removed prior authorization requirements for OUD medications. 15,16 However, prior authorization for buprenorphine is still common under Medicaid and private insurance. [17][18][19] Medicare Part D offers a unique opportunity to study the association of changes in prior authorization policies with the use of OUD medications and, more broadly, with health care Understanding how to improve OUD treatment access and outcomes among Medicare beneficiaries is important.…”

Section: Introductionmentioning

confidence: 99%

Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries

2020

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IMPORTANCE Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes. OBJECTIVE To determine the association of prior authorization with use of buprenorphinenaloxone and health care outcomes. DESIGN, SETTING, AND PARTICIPANTS This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020. EXPOSURES Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone. MAIN OUTCOMES AND MEASURES Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures. RESULTS The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, −0.2 to −0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, −0.13 to −0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, −4.3 to −0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, −3.2 to −0.1 visits per plan per year). CONCLUSIONS AND RELEVANCE Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.

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The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review

Cited by 46 publications

References 45 publications

Medicare Prescription Drug Plan Coverage of Hormone Therapies Used by Transgender Individuals

Medicare Prescription Drug Plan Coverage of Hormone Therapies Used by Transgender Individuals

Medical Financial Hardship among Cancer Survivors in the United States: What Do We Know? What Do We Need to Know?

Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries

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