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Am J Manag Care. 2014 Apr;20(4):322-31.

How does drug coverage vary by insurance type? Analysis of argue formularies in the United States.

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  • 1St Alban Vorstadt 49A, CH-Basel 4052, Switzerland. E-mail:



To quantify how access to on-patent drugs by tier placement varies by insurance type and therapeutic area.


Retrospective analysis of insurance plan drug coverage data.


Drug coverage information was collected from the Fingertip Formulary database in May 2011 for 3 drug classes (statins, angiotensin II receptor blockers, and protein-tyrosine kinase inhibitors) across 3 therapeutic areas with varying levels of generic drug availability. A generalized linear model was used to estimate the percentage of available on-patent drugs covered in the formulary tiers with lowest copay requirements (tiers 1 and 2) in different types of healthcare insurance plans in the United States.


There were substantial differences between insurance types in the number of on-patent drugs reimbursed in tiers 1 and 2 (ie, with a low copay). Compared with commercial plans, there were more on-patent drugs reimbursed with a low copay in employer plans, union plans, and with pharmacy benefit management companies, and substantially fewer on-patent drugs with a low copay in Medicare plans (Medicare Advantage, special needs, prescription drug plans) and discount prescription programs. These results were expected, as union plans are known for their generosity and Medicare plans rely heavily on cost containment (eg, cost sharing). For commercial Medicaid and municipal plans, the findings were dependent on the therapeutic class, or were inconclusive. The number of competitors a plan faces did not consistently affect the coverage of on-patent drugs.


The degree of coverage of on-patent drugs in the lowest copay tiers varies dramatically between insurance types, especially for expensive protein-tyrosine kinase inhibitors.

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