Prior authorization requirements for oral cancer drugs on Medicare part D formularies have increased in recent years, according to research published in JAMA.
Researchers used Medicare Part D formulary files to identify plans’ use of prior authorization, quantity limits, and step therapy for each drug-dose-formulary combination of oral cancer drugs from 2010 to 2020.
The number of Medicare beneficiaries enrolled increased from 28,030,290 in 2010 to 47,337,020 in 2020. The number of formularies increased from 333 to 548, and the number of oral cancer drugs increased from 62 to 249.
In 2010, there were 28 non-specialty brand name drugs, 26 specialty brand name drugs, 8 non-specialty generic drugs, and no specialty generic drugs. In 2020, there were 139 specialty brand name drugs, 86 non-specialty brand name drugs, 15 non-specialty generic drugs, and 9 specialty generic drugs.
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Utilization management increased over the study period, with prior authorization being the most common strategy for specialty and non-specialty brand name drugs as well as specialty generic drugs.
The proportion of drugs that required prior authorization increased from:
- 72.8% to 95.4% for specialty brand name drugs (from 2010 to 2020)
- 15.9% to 78.2% for non-specialty brand name drugs (from 2010 to 2020)
- 1.0% to 8.0% for non-specialty generic drugs (from 2010 to 2020)
- 91.1% to 95.0% for specialty generic drugs (from market entry in 2016 to 2020).
The requirement for quantity limits also increased over time and was the most common strategy for non-specialty generic drugs. The proportion of drugs that required quantity limits increased from:
- 31.4% to 62.5% for specialty brand name drugs (from 2010 to 2020)
- 11.8% to 47.3% for non-specialty brand name drugs (from 2010 to 2020)
- 9.7% to 18.8% for non-specialty generic drugs (from 2010 to 2020)
- 32.7% to 77.8% for specialty generic drugs (from 2016 to 2020).
The use of step therapy was rare across categories, with less than 1% of drug-dose-formulary combinations requiring step therapy from 2013 onward.
“Utilization management may be appropriate for some oncology drugs, such as those approved with provisional evidence of efficacy,” the researchers wrote. “It is less clear why prior authorization is required for highly effective, first-line drugs such as generic imatinib. Policies aimed at reforming utilization management should prioritize reducing barriers to high-value treatment.”
Reference
Kyle MA, Dusetzina SB, Keating NL. Utilization management trends in Medicare part D oncology drugs, 2010-2020. JAMA. Published online July 18, 2023. doi:10.1001/jama.2023.10753
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