Medicare Drug Plans Often Charge More Than Cost Plus for Common Antiemetic
Despite ondansetron becoming increasingly affordable, Medicare Advantage and Part D prescription drug plans frequently use tools that make it harder for patients to access this anti-nausea medication. A new study has found that both plan types often implement prior authorization and quantity limits, and while Medicare Advantage plans typically have lower costs than Part D, both tend to charge significantly more than a direct-to-consumer pharmacy known for transparent, low pricing.
Accessibility Barriers Within Medicare Plans
The study, published in JAMA Network Open, examined data from more than 4,300 Medicare Part D and Medicare Advantage prescription drug plans from the third quarter of 2023. Researchers analyzed the use of management tools – like prior authorization and quantity limits – for oral ondansetron across both plan types. They also compared the prices for various formulations of ondansetron between the plans and the cost of purchasing from the Mark Cuban Cost Plus Drug Company, which operates under a fixed markup pricing model.
Prior Authorization and Quantity Limits Common
Researchers found that Medicare Advantage plans were more likely to implement both prior authorization and quantity limits compared to Part D plans. Nearly 90% of Medicare Advantage plans required prior authorization for ondansetron, while about 72% of Part D plans did. Similarly, over 22% of Medicare Advantage plans employed quantity limits, compared to about 17% of Part D plans.
“These findings highlight concerning access barriers to essential medications, even when generic options are readily available and affordable,” the authors wrote.
Cost Comparisons Show Significant Differences
While Medicare Advantage plans often had lower out-of-pocket costs compared to Part D plans for both 4mg and 8mg ondansetron tablets, both plan types charged significantly more than the Cost Plus Drug Company for all included formulations. For example, Medicare Advantage plans charged an average of $24.40 for 30 4mg tablets compared to $9.50 from the Cost Plus Drug Company.
The authors underscored the implications for patients reliance on Medicare for their healthcare needs. “Despite ondansetron’s decreasing costs, most Medicare Advantage and Part D prescription drug plans continue to enforce substantial utilization management, limiting patients’ timely access while increasing clinicians’ administrative burdens,” they wrote. “Policymakers must prioritize access to high-value medications to prevent unnecessary delays and cost in care.”
Study Limitations and Further Research
The study employed plan-level data, which limited analysis focused on individual patient outcomes. Future research could benefit from examining the real-world impact on patients’ access to and utilization of ondansetron.
* How do the findings of this study compare to access patterns for other essential generic medications under Medicare?
## Behind the Headlines: High Costs for a Common Anti-Nausea Drug
**Interviewer:** Joining us today is Dr. Alex Reed, a researcher who recently published a study in JAMA Network Open about access to the anti-nausea medication ondansetron under Medicare. Dr. Alex Reed, thank you for being here.
**Dr. Alex Reed:** Thank you for having me.
**Interviewer:** Your research found that despite ondansetron becoming more affordable, many Medicare plans make it difficult for patients to access this medication. Can you tell us more about that?
**Dr. Alex Reed:** Absolutely. We found that both Medicare Advantage and Part D plans frequently use tools like prior authorization and quantity limits for oral ondansetron. This means patients often need their doctor to jump through extra hoops to get the medication approved, or they may not be able to get enough of it to manage their nausea effectively.
**Interviewer:** That sounds incredibly frustrating for patients. What else did your study reveal?
**Dr. Alex Reed:** We also found that both types of Medicare plans often charge significantly more for ondansetron than a direct-to-consumer pharmacy like Mark Cuban’s Cost Plus Drug Company, which is known for its transparent, low pricing. [[1](https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33827&DocID=L33827)]
**Interviewer:** So even though the drug itself is becoming more affordable, Medicare plans are making it more expensive for patients to access?
**Dr. Alex Reed:** Unfortunately, yes. This highlights a disconnect between the rising affordability of generic medications and the practices of some insurance plans.
**Interviewer:** What do you think needs to be done to address this issue?
**Dr. Alex Reed:** Greater transparency in pricing and formulary practices from Medicare Advantage and Part D plans is crucial. We also need to investigate the impact of prior authorization and quantity limits on patient care and explore policy solutions to ensure equitable access to essential medications.
**Interviewer:** Dr. Alex Reed, thank you for shedding light on this important issue.
