The Formulary Files

HMO, Medicaid formularies exhibit surprisingly small differences

When you compare HMO and Medicaid formularies for coverage in major therapeutic areas, you find that the differences are relatively small, with Medicaid plans being somewhat less stringent. Approximately 35 percent of commercial HMOs pay for proton pump inhibitors at an approved, Tier 1 or Tier 2 status, compared to Medicaid plans at over 40 percent.

Cox-2 inhibitors are paid at the approved, Tier 1 or Tier 2 level at approximately 20 percent of commercial HMOs, while over 30 percent of Medicaid plans pay at that level.

For SSRI anti-depressants, about 60 percent of both commercial HMO plans and Medicaid plans cover these products at the approved, first or second tier.

The only other significant difference is the rate at which HMOs use prior authorization for Cox-2 inhibitors compared to Medicaid. As you can see, more than 50 percent of HMOs list Cox-2s as requiring prior authorization versus approximately 40 percent of Medicaid plans.

This information is drawn from the MediMedia USA database Formulary Compass, which tracks medications on approximately 3,000 formularies in the U.S. representing HMOs, PPOs, Medicaid, PBMs and employer groups.


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Precision medicine, big data, Alzheimer’s Disease, migraine, and RNA therapeutics.
Learnings from the April 2018 meeting.
Edited by Jill Condello, PhD, ICON Access, Commercialisation & Communications