Medicaid Prescription Formulary Restrictions and Arthritis Treatment Costs

Abstract

Formularies that are more restrictive significantly change the patterns of health care and prescription drug use and may have unintended consequences in terms of more frequent and, for those with rheumatoid arthritis, more expensive medical care.

Medical Care Costs Associated With Rheumatoid Arthritis in the US: A Systematic Literature Review and Meta‐Analysis

“…Only one database, the Medical Expenditure Panel Survey, was used in more than one of the included studies. The included studies analyzed costs within a number of different medical insurance settings; 6 studies reported costs for privately insured patients (9) (10) (11) (12) (13) (14), 3 studies reported costs for patients enrolled in Medicaid programs (15) (16) (11), and 1 study reported costs for patients enrolled in Medicare (17). Additionally, 3 studies utilized patient data from large, national databases and used weighting to generalize their findings to be representative of the entire US population (18) (19) (20).…”

“…However, there was considerable variability in which codes were used and the number of instances of an RA code required for inclusion. Of the 11 studies using ICD-9-CM codes, 4 identified a narrow subset of codes to define RA (9) (15) (16) (14), while the rest accepted any code within the 714.xx series (10) (11) (12) (13) (17) (19) (20). Eight (73%) studies required only one instance of an RA code for inclusion; the remaining 3 (27%) required more than one instance of an RA code, or a combination of one RA code with either a claim for at least one DMARD or self-reported RA diagnosis.…”

Effects of delisting nonprescription combination drugs on health insurance expenditures for pharmaceuticals in Korea

“…Limitations in reimbursements for drugs and medications can also affect inpatient, outpatient, and laboratory test services [15,16]. Therefore, any policy for delisting or restricting reimbursements from benefits should consider other secondary effects, and it may be difficult to expect the total pharmaceutical expenditure to decrease in response to a specific intervention program.…”

Systematic reviews reveal unrepresentative evidence for the development of drug formularies for poor and nonwhite populations

“…A recent study that compared Medicaid plans found that plans that severely limited the number of NSAIDS on their PDLs actually spent more money on their arthritis patients than less restrictive plans [95], but it is unclear if this effect would be found for differently structured formularies or other drug classes or medical conditions. Well-designed drug formularies can encourage the use of time-tested, relatively inexpensive generic drugs and encourage their use as a first step in treatment, before trying newer and heavily marketed drugs that may not provide more benefit to patients.…”