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Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2016


This report fulfills the annual reporting mandate from the Patient Protection and Affordable Care Act (ACA) for 2016. The ACA requires OIG to conduct a study of the extent to which formularies used by Medicare Part D plans (i.e., stand-alone prescription drug plans and Medicare Advantage prescription drug plans) include drugs commonly used by full benefit dual eligible individuals (i.e., individuals who are eligible for both Medicare and full Medicaid benefits). Pursuant to the ACA, OIG must annually issue a report with recommendations as appropriate. This is the sixth report the OIG has produced to meet this mandate.


For this report, we determined whether the 347 unique formularies used by the 3,116 Part D plans operating in 2016 cover the 200 drugs most commonly used by dual eligibles. We also determined the extent to which those commonly used drugs are subject to utilization management tools. To create the list of the 200 drugs most commonly used by dual eligibles, we used the 2012 Medicare Current Beneficiary Survey. Of these 200 drugs, 198 are eligible for Part D prescription drug coverage, 1 is excluded from coverage, and 1 is no longer prescribed in the form taken by beneficiaries.


Overall, we found that the rate of Part D plan formularies' inclusion of the 198 drugs commonly used by dual eligibles is high, with some variation. On average, Part D plan formularies include 96 percent of the 198 commonly used drugs. In addition, 68 percent of the commonly used drugs are included by all Part D plan formularies. These results are largely unchanged from OIG's findings for formularies reported in the 2015 mandated annual report.

We also found that the percentage of drugs subject to utilization management tools remained relatively the same from 2015 to 2016. On average, formularies applied utilization management tools to 28 percent of the unique drugs we reviewed in 2016, compared to 29 percent of those we reviewed in 2015.

This report does not contain recommendations.