Huiwen Deng, Sarah Lothspeich, Darin Meinen, Abigail Sakellaris Mentored by Dr. Urmie
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1 Huiwen Deng, Sarah Lothspeich, Darin Meinen, Abigail Sakellaris Mentored by Dr. Urmie
2 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
3 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.
4 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)
5 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. 1 st through January 31 st
6 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. 15 th through Dec. 7th
7 Data collected Both disease states used the same ACA Exchange and PartD plans (same formularies) Examined cost sharing (premium costs, out-ofpocket costs, deductible amounts) Examined formulary/non-formulary, PA requirement, step therapy requirement, supply limit and specific tier
8 Percent of Cystic Fibrosis Drugs on Formulary Tobramycin Tobi Pulmozyme Kalydeco Orkambi Exchange Plans Part D Plan Cayston 100% 94% Orkambi 77% 100% Kalydeco 92% 100% Pulmozyme 100% 100% Tobi 62% 56% Tobramycin 85% 81% Cayston 0% 20% 40% 60% 80% 100% 120% Part D Plan Exchange Plans
9 Percent of Plans Requiring a PA for Cystic Fibrosis Dugs Tobramycin Exchange Plans Part D Plan Tobi Pulmozyme Kalydeco Orkambi Cayston 69% 73% Orkambi 100% 100% Kalydeco 92% 94% Pulmozyme 62% 63% Tobi 67% 67% Tobramycin 64% 69% Cayston 0% 20% 40% 60% 80% 100% 120% Part D Plan Exchange Plans
10 Average Cystic Fibrosis Drug Cost in Exchange Plans by State Cayston Orkambi Kalydeco Pulmozyme Tobi Tobramycin Wisconsin Texas Pennsylvania Oregon
11 Average Cystic Fibrosis Drug Cost in PartD Plans by State Cayson Orkambi Kalydeco Pulmozyme Tobi Tobramycin Wisconsin Texas Pennsylvania Oregon
12 Percentage of Dementia Drugs on Formulary Donepezil Exelon Rivastigmine Ergoloid Mesylate Galantamine Hydrobromide Razadyne Memantine HCl Namenda 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% Namzaric 0% 20% 40% 60% 80% 100% 120% Part D plans Exchange plans
13 Donepezil Exelon Rivastigmine Ergoloid Mesylate Galantamine Hydrobromide Razadyne Memantine HCl Percentage of Plans that Required PA for Dementia Drugs 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% Namenda Namzaric 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Part D plans Exchange plans
14 Tier Ranges for Dementia Drugs in Exchange plans Namzaric Namenda Memantine HCl* Razadyne Galantamine Hydrobromide Ergoloid Mesylate Rivastigmine Exelon Donepezil 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Tier 4 Tier3 Tier2 Tier1
15 Tier Ranges for Dementia Drugs in Part D plans Namzaric Namenda Memantine HCl Razadyne Galantamine Hydrbromide Ergoloid Mesylate Rivastigmine Exelon Donepezil 0% 10% 20% 30% 40% 50% 60% 70% 80% Tier 4 Tier 3 Tier 2 Tier 1
16 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
17 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
18 QUESTIONS? Huiwen Deng, Sarah Lothspeich, Darin Meinen, Abigail Sakellaris Mentored by Dr. Urmie
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