Market Access Insights From Review Of Us Formulary Coverage Trends For Top 100 Selling Drugs

United States health plans manage access and utilization of pharmaceutical drugs using formulary tier coverage, restrictions, co-pays and deductibles. Due to several new changes introduced by the Affordable Care Act, there is a need to understand how various health plans are annually changing access and utilization of drugs. The objective of this study was to review formulary coverage, utilization controls and cost sharing for top 100 selling drugs in the United States. The data for formulary tier status, prior authorization, quantity limits, co-pays and deductibles for top 100 selling drugs for Medicare Part D plans in top five states, covering ~116 million lives were obtained from CMS. The access trends were analyzed overall and for individual drugs for 2014 and 2015. In the selected five states, 6144 coverage policies were identified for top 100 selling drugs. Overall, in 2015, 43.11% of coverage was as a preferred brand, 27.25% at speciality tier and 24.98% as a non-preferred brand. Compared to 2014, in 2015, there was an absolute increase in speciality tier (+2%), decrease in preferred brand (-3.37%) and increase in non-preferred brand (+1.16%) coverage. In terms of Tier status, in 2015 the percentage of plans which covered the drugs at Tier 2, 3, 4 and 5 were 4.93%, 42.83%, 23.02%, and 29.22% respectively. Compared to 2014, the absolute percentage of plans with coverage at Tier 3 decreased (-2.31%) and Tier 5 increased significantly (+7.57%). In terms of utilization controls, compared to 2014, in 2015, there was a significant increase in prior authorizations (+3.99%), increase in quantity limits (+1.15%), slight increase in step therapy (+0.28%) and decrease in plans with no restrictions (-5.43%). The managed care coverage trends review shows an overall decrease in access for commonly prescribed branded drugs. This study suggests need for policy measures to improve access for drugs for patients.