Trends in Prescription Drug Coverage Restrictions in Medicare, Medicaid, and Commercial Insurance Plans, 2011-2019

Abstract Introduction Access to prescription drugs is an enduring challenge in patient care. Payers often rely on coverage restrictions to balance access and cost. Methods We assessed coverage restrictions for a comprehensive set of branded retail drugs without generic competitors from 2011-2019 across the four largest US market segments (Medicare, Medicaid, employer-sponsored, and health insurance exchanges) using CMS and Managed Market Insight and Technology (MMIT) data. Results Between 2011-2019, for the nationally representative beneficiary, the share of drugs excluded from formularies increased from 7.5% to 13.4%, the share of drugs subject to administrative restrictions such as prior authorization or step therapy increased from 18.1% to 43.7%, and the share of drugs on non-preferred tiers decreased from 57.8% to 42.2%. The share of drugs with any coverage restriction increased from 69.7 to 79.0%. Health plans and drugs subject to federal coverage mandates saw much larger increases in prior authorization and increases in non-preferred status. Conclusion These dynamics suggest that future research should study the tradeoffs between partial and full coverage restrictions for patient utilization, spending, and wellbeing.