P3829 - Medicare Part D Coverage Restrictions on Formulations Commonly Used for Pre-Colonoscopy Bowel Preparation, 2019-2024

Misha Gautam, MD¹, Utkarsh Goel, MD², Babu Mohan, MD^3
1University of Missouri - Kansas City School of Medicine, Kansas City, MO; ²Cleveland Clinic Foundation, Cleveland, OH; ³Orlando Gastroenterology PA, Orlando, FL

Introduction: Successful bowel preparation (prep) is critical for diagnostic accuracy of screening colonoscopies. Up to a quarter of preparations are suboptimal, impeding high quality colonoscopies (missing polyp/adenoma), increasing the likelihood of prolonged procedures and need for repeat procedures. High out of pocket costs and restrictions in access to bowel prep are significant barriers for patients accessing routine screening colonoscopy. In this study, we sought to assess payor-imposed utilization restricting strategies such as quantity limits and cost sharing tiers which are barriers to patients accessing commonly used laxative formulations for bowel preparation.

Methods: We evaluated eight unique laxative formulations commonly prescribed prior to colonoscopies using the Medicare Part D Prescription Drug Plan Formulary Files and analyzed the mean formulary tier placement, the proportion of stand-alone Medicare Part D plans adopting prior authorizations, and the proportion of plans imposing quantity limits for each formulation for the first quarters of 2019-2024.

Results: Bowel preparation laxative formulations on average were covered by 503 (range 0-1007) plans/year. None of the plans required prior authorization or imposed quantity limits from 2019-2024, both for brand name and generic formulations. The mean formulary tier placement was on a relatively higher Part D cost sharing tier (tier 3-4) for brand name formulations and remained constant over the study period (Figure 1). Similarly, the majority of plans placed the preps on tier 3 or higher for certain brand name formulations (100% for Plenvu, MoviPrep, GoLYTELY, and SUPREP), as compared to other preps (on average 3.2% for Polyethylene Glycol, GaviLyte).

Discussion: Over the 6-year study period, access to laxative preparations via Medicare Part D plans remained mostly liberal, with no plans requiring a prior authorization or imposing quantity limits. Encouragingly, the majority of preps were placed at a lower cost sharing tier. However, newer brand name formulations which are often lower volume (e.g., 4 L vs 1-2 L) and better tolerated, continue to be on a higher cost sharing tier. Provider education and advocacy efforts can ensure less restrictive access to patient preferred, highly effective low volume preps for Medicare Part D beneficiaries.



Disclosures:


Misha Gautam, MD¹, Utkarsh Goel, MD², Babu Mohan, MD³. P3829 - Medicare Part D Coverage Restrictions on Formulations Commonly Used for Pre-Colonoscopy Bowel Preparation, 2019-2024, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.