Understanding How Formulary Pricing Models Shape Medication Accessibility and Financial Burden for Aging Populations
Author(s)
Vishwanauth Persaud, PharmD1, Albert Wertheimer, PhD MBA2.
1Student, Touro College Of Pharmacy, New York, NY, USA, 2Social, Behavioral and Administrative Sciences, Touro College of Pharmacy, New York, NY, USA.
1Student, Touro College Of Pharmacy, New York, NY, USA, 2Social, Behavioral and Administrative Sciences, Touro College of Pharmacy, New York, NY, USA.
Presentation Documents
OBJECTIVES: This research examines the impact of Medicare formulary tier positioning on medication affordability, accessibility, and treatment compliance for elderly individuals in NYC, highlighting chronic conditions and promoting fair policy changes.
METHODS: This study examined Medicare formulary tier systems, the primary insurance model for elderly residents in New York City, focusing on medications for Alzheimer’s disease, COPD, rheumatoid arthritis, ischemic heart disease, and diabetes. Tier placement data from Medicare Part D formularies were analyzed, along with the criteria for assignment. The three most commonly prescribed drugs for each condition were identified using healthcare data and literature. An economic analysis assessed the costs of these medications, highlighting their financial impact on patients.
RESULTS: The research highlighted chronic illnesses among NYC's elderly, revealing inequalities in Medicare Formulary Tier medication affordability. Alzheimer’s treatments like galantamine and rivastigmine were often in higher tiers, raising out-of-pocket costs. COPD medications, including Symbicort and Trelegy Ellipta, despite preferred tier placement, posed financial challenges. Rheumatoid arthritis drugs, particularly Humira in Tier 5, imposed heavy costs. Similarly, ischemic heart disease and type 2 diabetes medications like Eliquis and Steglatro often appeared in higher tiers, worsening adherence issues.
CONCLUSIONS: Older patients in the U.S., particularly those dealing with chronic illnesses, still encounter significant financial pressure due to increasing prescription prices. Although initiatives such as the Inflation Reduction Act provide some assistance, the strain persists, leading to low compliance and adverse health results. The results highlight the urgent necessity for strong policies to improve price transparency, increase access to affordable generics, and stop the unjust classification of generics in higher tiers. Addressing these issues is crucial for attaining fair access to medications, especially for those who qualify for both Medicare and Medicaid.
METHODS: This study examined Medicare formulary tier systems, the primary insurance model for elderly residents in New York City, focusing on medications for Alzheimer’s disease, COPD, rheumatoid arthritis, ischemic heart disease, and diabetes. Tier placement data from Medicare Part D formularies were analyzed, along with the criteria for assignment. The three most commonly prescribed drugs for each condition were identified using healthcare data and literature. An economic analysis assessed the costs of these medications, highlighting their financial impact on patients.
RESULTS: The research highlighted chronic illnesses among NYC's elderly, revealing inequalities in Medicare Formulary Tier medication affordability. Alzheimer’s treatments like galantamine and rivastigmine were often in higher tiers, raising out-of-pocket costs. COPD medications, including Symbicort and Trelegy Ellipta, despite preferred tier placement, posed financial challenges. Rheumatoid arthritis drugs, particularly Humira in Tier 5, imposed heavy costs. Similarly, ischemic heart disease and type 2 diabetes medications like Eliquis and Steglatro often appeared in higher tiers, worsening adherence issues.
CONCLUSIONS: Older patients in the U.S., particularly those dealing with chronic illnesses, still encounter significant financial pressure due to increasing prescription prices. Although initiatives such as the Inflation Reduction Act provide some assistance, the strain persists, leading to low compliance and adverse health results. The results highlight the urgent necessity for strong policies to improve price transparency, increase access to affordable generics, and stop the unjust classification of generics in higher tiers. Addressing these issues is crucial for attaining fair access to medications, especially for those who qualify for both Medicare and Medicaid.
Conference/Value in Health Info
2025-05, ISPOR 2025, Montréal, Quebec, CA
Value in Health, Volume 28, Issue S1
Code
HPR167
Topic
Health Policy & Regulatory
Topic Subcategory
Health Disparities & Equity, Insurance Systems & National Health Care
Disease
No Additional Disease & Conditions/Specialized Treatment Areas, SDC: Geriatrics