DOAC use has shown improvements in safety and efficacy when compared to warfarin. Patients prefer DOACs over warfarin due to lack of monitoring and diet restrictions. Public insurance plans, like Medicare and Medicaid, manage medication coverage differently from commercial plan. Health plans use utilization management criteria (UMC) like step therapy, prior authorization, quantity limit and tiering status to optimize use of cost-effective therapies and to restrict utilization of high-cost therapies. This approach can impact patient care by limiting access. We suspect DOACs are susceptible to UMCs due to high cost and lack of generics available.
To describe formulary status, tier status and frequency of UMC applied to DOACs offered by Medicare, Medicaid, and Private plans.
Our descriptive study purchased data through Breakaway Partners. The data was queried in September 2019. All national insurance policies offering apixaban, rivaroxaban, dabigatran, and edoxaban were collected. Commercial insurance policies were excluded. The data set was separated into Medicare and Medicaid and private groups. Within each insurance policy group, the data was separated by DOAC agents. The formulary status, tier status, and UMC applied to each DOAC was counted and percentages were calculated. The three types of UMC counted were quantity limit (QL), prior authorization (PA), and step therapy (ST). All data analysis was performed with Microsoft Excel.
Apixaban and rivaroxaban were consistently listed as being on formulary more often than dabigatran and edoxaban (Table 1). Likewise, apixaban and rivaroxaban were more frequently listed as a lower tier compared to dabigatran and edoxaban across public and private payers (Table 1). When listed as being on formulary, QL was the most frequent UMC applied to a health plan. The exception was edoxaban offered by Medicaid plans which was most commonly restricted using PA.
Among all private health plans, apixaban and rivaroxaban were most commonly found as tier 2 medications. Whereas, dabigatran and edoxaban were most commonly found in tier 3 or 4 (table 1). Quantity limit was the most common UM criteria placed on DOACs. Among all DOACs that are included in this study edoxaban had the most restrictions (table 2).
Our study shows public insurance plans prefer apixaban and rivaroxaban over edoxaban and dabigatran. Our data set did not provide claims data or pricing structures. Future studies are needed to determine appropriateness of DOAC insurance policy management.
Our data shows that private health plans are making apixaban and rivaroxaban more readily available to patients when compared to dabigatran and edoxaban. Also, quantity limit is frequently utilized to restrict all four DOACs. Future research should evaluate the implementation of UM criteria of DOACs in the context of cost-effectiveness analyses done by ICER and other agencies.