New study finds insurers and PBMs increasing access restrictions in Medicare Part D
Medicare beneficiaries are facing greater access restrictions on their lifesaving medicines.
Medicare beneficiaries are facing greater access restrictions on their lifesaving medicines.
Medicare beneficiaries are facing greater access restrictions on their lifesaving medicines, according to a study by the Schaeffer Center at the University of Southern California recently published in Health Affairs. Looking at the Medicare Part D prescription drug benefit program, researchers found that health plans and pharmacy benefit managers (PBMs) are imposing more utilization management restrictions on prescription medicines or excluding the medicines from their formularies altogether. Here are some key findings:
At the same time, premiums charged by health plans are going up. As one of the study’s co-authors commented, “Plans are charging more and they’re covering less, so it’s a double whammy.”
This study builds on a previous report from the nonpartisan Government Accountability Office (GAO) showing patients in Medicare Part D paid billions more for medicines than insurers and PBMs.
When Congress passed the Inflation Reduction Act, it had an opportunity to fix these problems. Instead, the law’s price-setting provisions threaten to make these challenges even worse. The law does nothing to rein in abusive insurance and PBM practices. In fact, it does quite the opposite. The law creates perverse incentives for PBMs and health plans to make it even harder and more costly for patients to get their medicines.
As noted before, under the law, health plans can restrict patient access to certain treatments in favor of those that financially benefit insurers. They do this by imposing more utilization management rules on treatments, increasing patients’ out-of-pocket costs or refusing to cover other treatments on their formularies entirely.
Choice and access have long been hallmarks of the Medicare Part D program. It’s partly why the program has been so wildly popular with seniors. Congress must stop abuses of the program and protect seniors’ ability to get the treatments they need. They can start by requiring PBMs to share rebates with seniors at the pharmacy.