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Coverage of Atypical Antipsychotics Among Medicare Drug Plans in the State of Washington for Fiscal Year 2007

Prim Care Companion J Clin Psychiatry 2008;10(4):313-317
10.4088/PCC.v10n0407

Objective: To examine drug coverage and patient costs for 6 atypical antipsychotics (olanzapine, quetiapine, ziprasidone, aripiprazole, clozapine, and risperidone) in Medicare Part D formularies using health plan data from the state of Washington.

Method: Fiscal year 2007 coverage and cost-sharing characteristics for 57 prescription drug plans (PDPs) and 43 Medicare advantage prescription drug plans (MAPDs) were collected from the Centers for Medicare and Medicaid Services. Plans were compared in terms of formulary restrictions, out-of-pocket costs, and premium charges. Medicare released plan information for fiscal year 2007 in October 2006. Data were collected for this study in February 2007.

Results: Almost all plans covered the 6 atypical antipsychotics. The PDPs were more likely to restrict coverage than the MAPDs. Prior authorization requirements were enforced in 5% to 21% of plans, depending on plan type and medication. Monthly drug plan premiums were higher for PDPs than MAPDs, but the MAPDs had concurrent monthly health premiums. About 80% of MAPDs and 60% of PDPs also had no annual deductible for medications. The patient out-of-pocket cost for atypical antipsychotics varied depending on the stage of coverage-median monthly drug costs ranged from $5 to $50 during the initial period, but if costs exceeded the annual cap, patients were responsible for the full cost of the drug, which ranged from $292 to $665. Patients with low incomes and those who exceeded the annual spending limit ($3850 in fiscal year 2007) had a median monthly cost of $17 to $33.

Conclusions: There is considerable variation across health plans in terms of patients' out-of-pocket drug costs. Given the significant needs and vulnerabilities of Medicare beneficiaries with mental illness, changes for atypical antipsychotic coverage should be monitored carefully, and the complexity of Medicare drug plans should be minimized.