ArticleThe American journal of managed care2022
Medicare Advantage coverage restrictions for the costliest physician-administered drugs.
Article in The American journal of managed care, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
9 citing papers in PubMed.
- Quality, Cost, and Timeliness of Cancer Treatment in Medicare Advantage and Traditional Medicare.JAMA internal medicine · 2026Article
- Prior Authorization Requirements in Medicare Advantage and County Social Vulnerability.The American journal of managed care · 2026Article
- Health System Integration and Prior Authorization in Medicare Advantage.Health services research · 2026Article
- Payment Source Shift for Surgical Care Among Veterans Enrolled in Medicare Advantage Plans.JAMA health forum · 2025Article
- Resource Use and Care Quality Differences Among Medicare Beneficiaries Undergoing Chemotherapy.JAMA network open · 2024Article
- Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage.BMJ (Clinical research ed.) · 2024Article
- Importance of Patient Health Insurance Coverage and Out-of-Pocket Costs for Genomic Testing in Oncologists' Treatment Decisions.JCO oncology practice · 2024Article
- Increases in Medicare Spending and Use after Private Equity Acquisition of Retina Practices.Ophthalmology · 2024Article
- Prescribing of low- versus high-cost Part B drugs in Medicare Advantage and traditional Medicare.Health services research · 2022Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
Abstract
objectivesTo examine the use of step therapy, prior authorization, and Part D formulary exclusion by 4 large Medicare Advantage (MA) insurers to manage 20 physician-administered drugs with the highest total Medicare expenditures (top 20 drugs). STUDY
designWe collected data for United Healthcare, CVS/Aetna, Humana, and Kaiser plans to create a database of 2020 Part B coverage restrictions and conducted a retrospective analysis of 2018-2020 Part D formularies.
methodsFor each insurer, we calculated the number of top 20 physician-administered drugs subject to prior authorization and step therapy. For physician-administered drugs for which there were no similar or interchangeable alternatives, we examined which insurers required prior authorization or step therapy. Finally, we examined whether insurers restricted access to physician-administered drugs by reducing coverage on Part D formularies.
resultsOf the top 20 physician-administered drugs, 17 were subject to prior authorization and 10 were subject to step therapy by at least 1 insurer. For 5 physician-administered drugs without a similar or interchangeable alternative, none were subject to step therapy and all were subject to prior authorization by at least 1 insurer. Across the 4 insurers, 16 physician-administered drugs were covered on all or some of the Part D formularies in 2018, which decreased to 6 in 2020.
conclusionsFour large MA insurers managed access to expensive physician-administered drugs with a combination of prior authorization, step therapy, and Part D formulary design. When a low-cost alternative exists, these tools can help reduce wasteful spending, but the administrative barriers may also reduce access.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.