Huiwen Deng, Sarah Lothspeich, Darin Meinen, Abigail SakellarisMentored by Dr. Urmie

Formularies are important for patient access

Cost affects adherence

Formularies differ between plans

Especially regarding specialty medications

ACA Pre-Existing Conditions Mandate

Formularies can be a way around this

Pharmacists as a patient advocate

To evaluate different formularies in both PartD and ACA Exchange plans that are available in Wisconsin, Texas, Pennsylvania and Oregon to compare the coverage of specialty drugs required for Cystic Fibrosis and Dementia.

Examined disease states requiring specialty drugs Made a comprehensive list of drugs used for 4 specialty

disease states looking at 2-3 different plan formularies Looked at variation in formulary coverage and selected

Cystic Fibrosis and Dementia due to higher variation Surveyed states existing PartD and ACA Exchange

Plans Looked at number of insurance companies/plans offered

Locations selected Wisconsin (53719) Texas (75201) Pennsylvania (15214) Oregon (97205)

Chose ACA Exchange plans and PartD plans offered using the previous zip codes

Exchange Plans (through healthcare.gov)

Used silver plans if 4 different companies

If there were less than 4 companies used 1 silver plan from each company plus a bronze or gold to get to 4 total plans

Enrollment Nov. 1st

through January 31st

PartD Plans (through Medicare.gov) Typed in a common set of drugs (including at least

2 from each drug class) and chose a pharmacy

Careful to choose plans not requiring preferred pharmacies

1 plan was chosen from each of the four quartiles (e.g. 1 plan will be from the top 25% of plans by cost)

Enrollment Oct. 15th

through Dec. 7th

Data collected

Both disease states used the same ACA Exchange and PartD plans (same formularies)

Examined cost sharing (premium costs, out-of-pocket costs, deductible amounts)

Examined formulary/non-formulary, PA requirement, step therapy requirement, supply limit and specific tier

0% 20% 40% 60% 80% 100% 120%

Cayston

Orkambi

Kalydeco

Pulmozyme

Tobi

Tobramycin

Percent of Cystic Fibrosis Drugs on Formulary

Part D Plan Exchange Plans

Exchange Plans Part D Plan

Cayston 100% 94%

Orkambi 77% 100%

Kalydeco 92% 100%

Pulmozyme 100% 100%

Tobi 62% 56%

Tobramycin 85% 81%

0% 20% 40% 60% 80% 100% 120%

Cayston

Orkambi

Kalydeco

Pulmozyme

Tobi

Tobramycin

Percent of Plans Requiring a PA for Cystic Fibrosis Dugs

Part D Plan Exchange Plans

Exchange Plans Part D Plan

Cayston 69% 73%

Orkambi 100% 100%

Kalydeco 92% 94%

Pulmozyme 62% 63%

Tobi 67% 67%

Tobramycin 64% 69%

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Cayston Orkambi Kalydeco Pulmozyme Tobi Tobramycin

Average Cystic Fibrosis Drug Cost in Exchange Plans by State

Wisconsin Texas Pennsylvania Oregon

0

5000

10000

15000

20000

25000

30000

Cayson Orkambi Kalydeco Pulmozyme Tobi Tobramycin

Average Cystic Fibrosis Drug Cost in PartD Plans by State

Wisconsin Texas Pennsylvania Oregon

0% 20% 40% 60% 80% 100% 120%

Namzaric

Namenda

Memantine HCl

Razadyne

Galantamine Hydrobromide

Ergoloid Mesylate

Rivastigmine

Exelon

Donepezil

Percentage of Dementia Drugs on Formulary

Part D plans Exchange plans

Exchange plans Part D plans

Namzaric 31% 81%

Namenda 69% 81%

Memantine HCl 100% 100%

Razadyne 23% 6%

Galantamine Hydrobromide 100% 94%

Ergoloid Mesylate 92% 44%

Rivastigmine 100% 100%

Exelon 38% 19%

Donepezil 100% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Namzaric

Namenda

Memantine HCl

Razadyne

Galantamine Hydrobromide

Ergoloid Mesylate

Rivastigmine

Exelon

Donepezil

Percentage of Plans that Required PA for Dementia Drugs

Part D plans Exchange plans

Exchange plans Part D plans

Namzaric 25.0% 53.8%

Namenda 33.3% 92.3%

Memantine HCl 15.4% 81.3%

Razadyne 66.7% 0.0%

Galantamine Hydrobromide 7.7% 0.0%

Ergoloid Mesylate 8.3% 57.1%

Rivastigmine 15.4% 0.0%

Exelon 75.0% 0.0%

Donepezil 7.7% 0.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Donepezil

Exelon

Rivastigmine

Ergoloid Mesylate

Galantamine Hydrobromide

Razadyne

Memantine HCl*

Namenda

Namzaric

Tier Ranges for Dementia Drugs in Exchange plans

Tier 4 Tier3 Tier2 Tier1

0% 10% 20% 30% 40% 50% 60% 70% 80%

Donepezil

Exelon

Rivastigmine

Ergoloid Mesylate

Galantamine Hydrbromide

Razadyne

Memantine HCl

Namenda

Namzaric

Tier Ranges for Dementia Drugs in Part D plans

Tier 4 Tier 3 Tier 2 Tier 1

Medicare Part D vs ACA Exchange Both Medicare Part D and ACA Exchange plans have

similar percentages of the dementia drug class on formulary

The Medicare Part D plans tend to have more restrictions for dementia drugs when compared to the exchange plans

Medicare Part D plans and Exchange plans for Cystic Fibrosis were similar in terms of formulary restrictions and PA requirements

Largest difference was cost variation between states for Exchange plans

Overall, patients should choose plans carefully to ensure the lowest out of pocket cost and best coverage

Huiwen Deng, Sarah Lothspeich, Darin Meinen, Abigail SakellarisMentored by Dr. Urmie

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