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Invited Commentary
November 2015

Maintaining Access to Medications When Plans Implement Tiered Pharmacy Networks

Author Affiliations
  • 1Health Policy Institute, Georgetown University, Washington, DC

Copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2015;175(11):1853-1854. doi:10.1001/jamainternmed.2015.4994

Tiered pharmacy networks in Medicare drug plans and commercial insurance plans offer consumers incentives, typically lower cost sharing, to encourage use of pharmacies where health plans have negotiated discounts for prescription drugs. In the past 5 years, Medicare Part D has experienced dramatic growth in the use of tiered pharmacy networks. In 2011, only 7% of standalone Medicare Part D prescription drug plans (PDPs) had pharmacy networks where preferred (lower) cost sharing was offered in selected network pharmacies, rising to 72% by 2014.1 In 2015, 87% of PDPs have these networks. The cost savings can be substantial. In the AARP MedicareRx Saver Plus PDP, for example, the copayment in 2015 for a preferred brand drug is $20 in a pharmacy with preferred cost sharing and $45 in another network pharmacy without preferred cost sharing. Copayments in the Humana Walmart Rx PDP at a pharmacy with preferred cost sharing is $1 for drugs on the preferred generic tier and $4 for drugs on the nonpreferred generic tier, compared with $10 and $33, respectively, at other network pharmacies.2 The use of tiered pharmacy networks has also grown in commercial insurance; by one estimate3 nearly half of employer plans used them in 2014.

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