MANAGED CARE March 2009. ©MediMedia USA
Medical and pharmacy directors at Medicare Part D plans seem more inclined to create a separate specialty drug tier in their formulary design than their commercial counterparts.
Novartis’s Facts, Figures, & Forecasts, 2008–2009, reports that directors were asked to segment their enrollment by tiered copayment design options. Three fourths of the Medicare Advantage-Part D (MA-PDs) plans and stand-alone prescription drug plans (PDPs) had created a specialty tier in 2007, had introduced a specialty tier in 2008, or were planning to introduce a specialty tier in 2009.
Only 43 percent of commercial health plans reported having specialty tiers during that time.
Also reported were the types of drugs covered in the specialty drug tier. Most injectables were covered. Fewer plans covered oral oncologic agents and other oral agents on a specialty tier.
A number of these plans also designated drugs for the specialty tier based on member-cost threshold. Drugs with member costs starting as low as $500 per prescription, per month, or per claim were put on the specialty tier. A $600 member-cost threshold was most frequently reported by these plans.
The most common copayments for specialty tiers ranged between $25 and $250.
Source: Novartis Pharmacy Benefit Report. Facts, Figures, & Forecasts, 2008-2009.