In ACA-Required Report, HHS OIG Finds MA, Part D Plans Generally Cover Drugs Commonly Used by Dual Eligibles

Today, the Department of Health and Human Services’ Office of Inspector General (OIG) published anew report (highlights) finding that Medicare Advantage and Standalone Part D plan formularies generally cover prescription drugs commonly used by full-benefit dual eligibles, despite some variation across plans. The Affordable Care Act-required annual report, which does not contain any recommendations, has similar findings to previous iterations that initially were issued in 2011, with the OIG noting several components of the analysis were “largely unchanged.”

The study specifically looked at the 195 drugs most commonly used by dual eligibles (see a list on p.19 of the report, including the percentage of plan formularies including each). Among the findings:

• Part D plan formularies, on average, covered 96 percent of dual eligibles’ most commonly used drugs. The OIG notes that of 329 unique plan formularies reviewed, 18 included 100 percent of commonly used drugs, while “at the other end of the inclusion range, three formularies include 86 percent of the commonly used drugs.”
• Roughly 64 percent of the commonly used drugs were covered by all Part D plan formularies.
• The percentage of drugs subject to utilization management (UM) tools was about 28 percent, the same as in the 2013 report. The OIG notes that UM tools commonly included prior authorization, quantity limits and step therapy.
• Eighty-three percent of duals are enrolled in plans with premiums below the regional benchmark and 99 percent of duals have drug plans that include at least 90 percent of the commonly used drugs.

If you are interested in additional details about this hearing, please contact Arielle Kane (akane@thornrun.com).