2014 Medicare Drug Plans Vary Widely in Availability of Drugs and Restrictions

Slightly more drugs will be available under Medicare stand-alone prescription drug plans (PDPs) in 2014, and fewer will be available under the Medicare Advantage prescription drug benefit (MAPD), according to analysis by HealthPocket.

The variation is significant: MAPD plans range from 956 to 2,334, and PDP plans range from 995 to 2,333. On average, MAPD plans will include 1492 drugs on plan formularies, and PDP plans will include 1,456. An estimated 90% of Medicare enrollees have a drug benefit. As with the private health insurance market, each Medicare plan has a formulary. Consumers pay the full cost of drugs that are not on the plan formulary. Even if a drug is on the formulary, plans can restrict access by limiting the quantity, requiring prior authorization, and mandating a step therapy process for certain medications.

In 2014, MAPD plans will carry quantity limits on 0% to 32% of drugs, prior authorization on 3% to 37%, and step therapy on 0% to 11%. PDP plans will have quantity limits on 1% to 31% of drugs, prior authorization on 7% to 32%, and step therapy on 0% to 9%. Kaiser’s MAPD plan offers a high number of drugs, with 2,320 drugs on its formulary, approaching the industry maximum of 2,333. None of the drugs on its formulary carries quantity limits or step therapy restrictions, and prior authorization is required for only 3% of all drugs offered.

Steve Zaleznick of HealthPocket stressed that Medicare patients need to do their homework during open enrollment to figure out which plans give them the best deal. The most important question is whether their prescriptions are on the plan’s formulary and what hoops they may have to jump through to actually get the drugs, he added. Consumers can review Medicare plan options for free using HealthPocket’s Medicare comparison tool at http://www.healthpocket.com/medicare.

Last Updated 11/25/2020

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