Potential Access Implications of a National Formulary in Part D

While drug pricing proposals may seem a little distant given the current environment, it is likely that we will see legislative proposals surface sooner rather than later. As part of our planning, we wanted to revisit some research we did a few years ago on the differences between patient access in Medicare Part D (Part D) and the Veterans Affairs (VA) national formulary.

There continues to be some who favor government negotiated prices in Part D, but we wanted to gauge the potential impact on access. For this updated analysis, Xcenda again compared 25 Food and Drug Administration (FDA)-approved, first-in-class drugs among all Part D plans and the VA national formulary, with the premise of a government-run or -set formulary would likely be necessary for any proposal to be effective. We also looked at the top 200 Part D brand drugs in terms of total spend. 

• Of 25 FDA approved first-in-class therapies, Part D plans covered 62 percent on average whereas coverage under the VA was 40 percent.

• The VA could cover 103 (52%) of the top 200 Part D brand drugs compared to an average of 151 (75%) for Medicare Advantage prescription drug plans (MA-PD plans) and 139 (70%) stand-alone prescription drug plans (PDPs), or 149 (74%) under Part D overall.

The results suggest that moving to a national formulary would hinder patient access (and provider choice). The balance of risk-reward needs to be part of any conversation.

Download the full report titled, Comparing the Generosity of Drug Coverage in the Medicare Part D and Veterans Affairs Programs, below.