Drug Costs For Seniors Vary Widely Among Medicare Part D Plans

Humana Enhanced (PDP) is Best Value Plan in 26 states

Medicare Part D, the prescription drug benefit for seniors and the disabled, requires insurance policies to cover at least two drugs in most medication categories¹. However, which drugs are covered within a given medication category is left to the discretion of the company providing the insurance plan. Drugs that are covered by a specific Part D plan benefit not only from reduced out-of-pocket costs but also protections from catastrophic financial expenses. Uncovered drugs, on the other hand, carry with them no protections with respect to catastrophic out-of-pocket costs.

While it is generally known that uncovered drugs are paid for completely out-of-pocket, it is not widely understood that the same drug covered by two different Medicare Part D plans can charge different amounts. These differences in drug charges (whether copayments or coinsurance fees) can significantly affect the economic value of the Part D plan for someone on Medicare.

HealthPocket analyzed the lists of covered drugs (i.e. formularies) for all 2014 Medicare Part D insurance plans sold in the United States to evaluate their drug coverage. For each of the top 50 drugs² sold in the U.S. and for each Medicare Part D plan, HealthPocket estimated the amount a beneficiary would pay for premiums and prescriptions, and then combined the results across all 50 drugs for each plan.

HealthPocket also noted the number of top 50 drugs covered by the plan. When a particular drug was uncovered, an estimated retail price for that drug was used within the plan’s combined costs for the top 50 drugs. For covered drugs, the plan’s cost-sharing for the medication was used and assumed one prescription fulfillment per month for 12 months.

Medicare Part D Rankings By State

* Based on a default dosage & quantity for each drug prescription filled once a month for one calendar year. If a drug was uncovered, then an estimated retail price was used for the drug cost. Cost estimates were performed separately for each of the 50 drugs and then combined together for a single total cost.

Based on the research summarized in the above table, Arizona had the Medicare Part D plan with the lowest costs. The combined costs for the 50 most popular drugs for the AARP MedicareRx Preferred (PDP) were $64,013.45. Illinois had the Medicare Part D plan with the highest combined costs. The combined costs for the 50 most popular drugs for the Health Alliance Medicare Prescription Plan - Basic (PDP) were $163,451.03.

The Humana Enhanced (PDP) had the lowest cost in the most states when using the top 50 drugs to evaluate costs. It was the lowest cost Part D plan in 26 states and covered 48 of the top 50 drugs.

The Aetna Medicare Rx Premier (PDP) had the highest cost in the most states when using the top 50 drugs to evaluate costs. It was the highest cost Part D plan in 37 states and covered 41 of the top 50 drugs.

The plan that was the lowest cost option in each state covered 47.6 of the top 50 drugs on average. In comparison, the plan that was the highest cost option covered 39.9 of the top 50 drugs.

CONCLUSION

HealthPocket’s research found that costs for the top 50 drugs varied widely among Medicare Part D plans. For the combined costs of the top 50 drugs, the highest cost Part D plan in the nation had 155% greater costs than the lowest cost Part D plan in the nation. On average the highest cost Part D plan in each state had 109% greater costs than the lowest cost Part D plan in the same state. HealthPocket recommends that consumers include their state winner within their shopping comparisons while remembering that their personal out-of-pocket costs are specific to the medications that they take.

Both premiums and cost-sharing (including deductibles, copayments, and coinsurance) should be taken into consideration when evaluating Medicare Part D options. Additionally, consumers are advised to watch for drug restrictions that could potentially affect them. In some cases, a Part D plan may require a doctor to request and receive approval for a specific drug prescription before the plan will contribute towards that drug’s costs. In other cases, a plan may require a beneficiary to try a less expensive drug and establish it is insufficiently effective before the plan will approve a very expensive drug.

METHODOLOGY

The cost for each of the top 50 drugs on a Medicare prescription drug plan, including premiums, was determined by using a default quantity/dosage for the medication and assuming that quantity/dosage was filled once a month on the Medicare prescription drug plan. The separate costs for each of the 50 drugs on a particular Medicare prescription drug plan were then combined together. Medicare Part C plans, otherwise known as Medicare Advantage plans, were not evaluated as part of this study.

The list of top 50 most popular drugs in the United States was based on the units of prescription drugs sold in Q4 of 2013: “U.S. Pharmaceutical Sales - Q4 2013” Drugs.com. Last updated February 2014. http://www.drugs.com/stats/top100/units. The default quantity/dosage amount for each drug used in this study was taken from the default quantity/dosage amounts displayed on Medicare.gov for each of the 50 drugs investigated.

Medicare prescription drug plan formulary information and cost-sharing tiers were obtained from the Centers of Medicare & Medicaid Services’ Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information Files for 2014 quarter 1. Part D plans with contract IDs of S0064, S3521, S7230, and S7610 were excluded from this analysis since they lacked formulary data.

The following national drug codes (NDC) were used for the top 50 drugs: 003787155, 006033881, 593100579, 003781809, 001730682, 001865040, 001730696, 000882219, 000023270, 000882220, 620370849, 003100751, 001693687, 003780032, 005970075, 001696339, 000027510, 001697501, 591480008, 000746624, 000060277, 000851288, 000711014, 001860370, 000040800, 665820414, 004563210, 001730719, 000780359, 124961208, 001155522, 578940030, 000518450, 000239163, 001680204, 647640175, 655970103, 001730783, 504580579, 000028799, 590110420, 512480150, 584060435, 000251525, 005970024, 665820313, 000024462, 000060577, 005970135, 553900110.

All drug cost-sharing estimates assume the use of an in-network pharmacy. In cases of a multi-tier pharmacy network, a pharmacy in the preferred tier with the lowest cost-sharing was used.

AUTHORS

This analysis was written by Kev Coleman, Head of Research and Data at HealthPocket, with primary research performed by Jesse Geneson, Data Researcher at HealthPocket, and additional data analysis performed by Katherine Bian. Correspondence regarding this study can be directed to Mr. Geneson at jesse.geneson@healthpocket.com.

Feedback and questions are welcome but, given the volume of email, personal responses may not be feasible.

Jesse Geneson on Google+
Kev Coleman on Google+

SOURCES

¹ “Each category or class must include at least two drugs (unless only one drug is available for a particular category or class, or only two drugs are available but one drug is clinically superior to the other for a particular category or class), regardless of the classification system that is utilized. The two drug minimum requirement must be met through the provision of two chemically distinct drugs.” “30.2.1 - Formulary Categories and Classes” within chapter 6 (Rev. 10, 02-19-10) of the Pub. 100-18 Medicare Prescription Drug Benefit Manual. Medicare also requires that all, or substantially all, of the drugs in the following 6 drug classes be covered: Antidepressants, antipsychotics, anticonvulsants, antineoplastics (used by cancer patients), immunosuppressants (used by transplant patients), and antiretrovirals (used by patients with HIV).
² The list of top 50 drugs was based on units of drugs sold in Q4 of 2013. “U.S. Pharmaceutical Sales - Q4 2013” Drugs.com. Last updated February 2014. http://www.drugs.com/stats/top100/units. Accessed May 9, 2014.
³ Despite being fourth on the list of the top 50 drugs by units sold, OneTouch Ultra was not included in this study since it is a blood glucose monitor and not a prescription drug. OneTouch Ultra is covered by Medicare Part B, but not by Part D. http://www.onetouch.com/articles/medicare-coverage-for-diabetes-supplies