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Insights from Analysis of Formulary Coverage Trends for Generics with High Price Increases

With medication expenditures rising, generic drugs still are seen as a valuable and affordable option for patients across many disease states. Generics have customarily been covered at Tier 1 with copays of $5-$10. Lately, however, the cost of these drugs have risen, at times, into the triple digits, prompting researchers to question how the increased cost is impacting access to generic medications.

Saurabh Aggarwal, PhD, NOVEL Health Strategies, Ellicott City, MD, and colleagues, initiated a systematic literature review to analyze the access trends in U.S. health plans. Researchers looked at coverage trends for generic drugs with significant price increases, obtaining the data from CMS for these drugs for all health plans. For each of the 829 coverage policies identified, Aggarwal and colleagues collected the drug name, tier status, deductibles, and type of restrictions. They also looked at the coverage trends based on drug name, state level and at a national level.

“We identified five generic drugs whose price was increased by 500-5,000% during the last 24 months—doxycycline glycopyrrolate, pravastatin, lisinopril, pyrimethamine,” he said, demonstrating how substantial these increases have become.

Two key coverage trends emerged:

  • Only 30% of plans covered these generic drugs at Tier 1. The other 24%, 19% and 23% of the plans covered the selected generic drugs at Tier 2, 3 and 4, respectively.
  • Only 24% of the plans covered these drugs as a generic, others covered them as non-preferred brand (24%), preferred brand (18%) and preferred generic (28%).

Researchers also found that the patient copay and coinsurance differed significantly across plans and type of formulation.

“For example, for doxycycline oral,” Aggarwal said, “few plans—15%—still have a low copay of $5-$10, while majority have coinsurance ranging from 25%-47%. Similarly, injectable formulation of Glycopyrrolate has coinsurance of 33%-47%, which can lead to a high patient cost share of $1,400 per month. [We concluded that] patient access for some generic drugs has been restricted significantly.”


Abstract U26