Even when medications are covered (i.e., not considered benefit exclusions), employers use a range of coverage limitations to promote appropriate use. The most effective UM programs, such as prior authorization (PA), days supply limits, and step therapy use a hard edit (i.e., point-of-sale reject) in the adjudication process at the pharmacy to deny coverage that falls outside plan guidelines. The most popular UM tools continue to be prior authorization (76%), quantity limits (74%), and refill to soon (72%). Use of UM tools varies significantly by type of employer (Figure 31). Carve-out plans were more likely to use PA, quantity limits, and refill-too-soon limits (p<.05). Use of these three tools was highest among selfinsured carve-out employers.
More than half of respondents (56%) now have step therapy for one or more therapy classes. When examined for key therapy classes, step therapy is most common for depression (44%), followed closely by asthma at 41%, and high cholesterol (40%; Figure 32). Other therapy classes that frequently use step therapy, although not examined here, include the PPIs and nonsteroidal anti-inflammatories.
Figures 33 to 37 show the use of UM tools for each of the five therapy classes examined. For each of these classes, refill too soon limits are the most common UM tool, used by just over half of respondents. For asthma, quantity limits are the second most popular tool, used by just over half of respondents as well. Step therapy is the second most commonly used UM tool for depression (44%), and high cholesterol (40%).
Among all of the drug classes most commonly excluded from the benefit, oral contraceptives, diabetic supplies, non-sedating antihistamines, and OTC drugs are the least likely to have UM limitations when covered (Figure 38). As in previous years, prior authorization is used most frequently to manage growth hormones, experimental and investigational drugs, injectables, and Retin A® (Figure 39). As shown in Figure 40, a days supply limit is used most commonly for erectile dysfunction (54%), sleep disorder (35%), and smoking cessation (34%). Other, nonspecified strategies are commonly used for infertility and OTCs.
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