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OFFICE OF INSPECTOR GENERAL 
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JUN 11 2014 
TO: 	 Marilyn Tavenner 
Administrator 
Centers for Medicare & Medicaid Services 
FROM:  Brian P. Ritchie 
Acting Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report : Part D Plans Generally Include Drugs Commonly 
Used by Dual Eligibles:  2014 , OEI-05-14-00170 
This memorandum report fulfills the annual reporting mandate from the Patient 
Protection and Affordable Care Act of 20 I 0 (ACA) for 2014 . The ACA requires that the 
Office of Inspector General (OIG) conduct a study of the extent to which formularies 
used by stand-alone prescription drug plans (PDP) and Medicare Advantage prescription 
drug plans (MA-PD) under Medicare Part D include drugs commonly used by full-benefit 
dual-eligible indi viduals (i.e. , individuals who are eligible for both Medicare and 
Medicaid and who receive full Medicaid benefits and assistance with Medicare premiums 
and cost-sharing) . 1  Pursuant to the ACA, OIG must annually issue a report, with 
recommendations as appropriate.  This is the fourth report that OIG has produced to meet 
this mandate .  For the relevant text of the ACA , see Appendix A 
SUMMARY 
Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (MMA) , comprehensive prescription drug coverage under Medicare Part D is 
available to all Medicare beneficiaries through PDPs and MA-PDs (hereinafter referred 
to collectively as Part D plans). 2 
For beneficiaries who are eligible for Medicare and Medicaid (hereinafter referred to as 
dual eligibles) , Medicare covers Part D plan premiums, deductibles, and other 
cost-sharing up to a determined premium benchmark that varies by region. 
1 ACA. P.L No. 111-148  3313(a), 42 U.S.C.  1395w-101 note . 

2 MMA . P.L N o. 108-173  101 , Social Security Act, 18600-l (a) , 42 U.S.C.  1395w-l0l(a). 
 Page 2  Marilyn Tavenner 
If dual eligibles enroll in Part D plans with premiums higher than the regional 
benchmark, they are responsible for paying the premium amounts above that benchmark. 
 
To control costs and ensure the safe use of drugs, Part D plans are allowed to establish 
formularies from which they may omit drugs from prescription coverage and control drug 
utilization through utilization management tools.3  These tools include prior 
authorization, quantity limits, and step therapy.4     
 
The Centers for Medicare & Medicaid Services (CMS) annually reviews Part D plan 
formularies to ensure that they include a range of drugs in a broad distribution of 
therapeutic categories or classes.  CMS also assesses the utilization management tools 
present in each formulary. 
 
For this memorandum report, we determined whether the 329 unique formularies used by 
the 3,309 Part D plans operating in 2014 cover the 200 drugs most commonly used by 
dual eligibles.  We also determined the extent to which those commonly used drugs are 
subject to utilization management tools.   
 
Overall, we found that the rate of Part D plan formularies inclusion of the drugs 
commonly used by dual eligibles is high, with some variation.  On average, Part D plan 
formularies include 96 percent of the commonly used drugs.  In addition, 64 percent of 
the commonly used drugs are included by all Part D plan formularies.   
 
We also found that from 2013 to 2014, the proportion of unique drugs subject to 
utilization management tools remained the same.  On average, formularies applied 
utilization management tools to 28 percent of the unique drugs we reviewed in both 2013 
and 2014. 
 
The results of our analysis for 2014 are largely unchanged from OIGs findings in 2011, 
2012, and 2013.5, 6  7  
 
 
 
 
                                                 
3 A formulary is a list of drugs  covered by a Part D plan.  Part D plans can exclude drugs from their 

formularies and can control utilization for formulary-included  drugs within certain  parameters.  Social 

Security Act  1860D-4(b) and  (c), 42  U.S.C.  1395w-104(b) and  (c).   

4 Prior authorizationoften required for very expensive drugsrequires that physicians obtain approval 
 
from Part D plans to  prescribe a specific drug.  Quantity limits are intended to ensure that beneficiaries 

receive the proper dose and recommended duration of drug therapy.  Step therapy is the practice of 

beginning drug therapy for a medical condition with the most cost-effective or safest  drug therapy and 

progressing if  necessary to more costly or  risky drug therapy. 

5 OIG,  Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles, OEI-05-10-00390, 

April 2011. 

6 OIG,  Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2012, 

OEI-05-12-00060, June 2012. 

7 OIG,  Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2013, 

OEI-15-13-00090, June 2013. 

Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 3  Marilyn Tavenner 
BACKGROUND 
 
The Medicare Prescription Drug Benefit 
Beginning in 2006, the MMA made comprehensive prescription drug coverage under 
Medicare Part D available to all Medicare beneficiaries.8  Medicare beneficiaries 
generally have the option to enroll in a PDP and receive all other Medicare benefits on a 
fee-for-service basis, or to enroll in an MA-PD and receive all of their Medicare benefits, 
including prescription drug coverage, through managed care.  As of March 2014, 
approximately 37.3 million of the  50.8 million Medicare beneficiaries were enrolled in a 
Part D plan. 
 
Part D plans are administered by private companies, known as plan sponsors, that 
contract with CMS to offer prescription drug coverage in one or more PDP or MA-PD 
regions. CMS has designated 34 PDP regions and 26 MA-PD regions.9  In 2014, plan 
sponsors offer 3,309 unique Part D plans, with many plan sponsors offering multiple 
Part D plans. 
 
Dual Eligibles Under Medicare Part D 
Approximately 9.7 million Medicare beneficiaries are dual eligibles.  About 7 million 
dual eligibles, referred to as full-benefit dual eligibles, receive full Medicaid benefits  
and assistance with Medicare premiums and cost-sharing.10  Other dual eligibles receive  
assistance with only their Medicare premiums  or cost-sharing, depending on their level of 
income and assets. 
 
Dual eligibles are a particularly vulnerable population.  Overall, most dual eligibles have 
very low incomes:  86 percent have annual incomes below 150 percent of the Federal 
poverty level, compared with 22 percent of all other Medicare beneficiaries.11   
Additionally, dual eligibles are in worse health than the average Medicare beneficiary:  
half are in fair or poor health, more than twice the rate of others in Medicare.12  Because 
of their self-reported health needs, dual eligibles may use more prescription drugs and 
health care services in general than other Medicare beneficiaries. 
 
Until December 31, 2005, dual eligibles received outpatient prescription drug benefits 
through Medicaid. In January 2006, Medicare began covering outpatient prescription 
drugs for dual eligibles through Part D plans.13    
 
                                                 
8  MMA, P.L. No. 108-173  101, Social Security Act,  1860D-1(a), 42 U.S.C.   1395w-101(a). 

9 CMS, Prescription Drug Benefit Manual (PDBM), Pub. 100-18, ch. 5, Appendixes 2 and 3.  Accessed at 

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/
  
PartDManuals.html  on October 19, 2012.  

10 Kaiser Family Foundation,  Dual  Eligibles:  Medicaids Role for Dual Eligible. Accessed at 

http://kaiserfamilyfoundation.files.wordpress.com/2013/08/7846-04-medicaids-role-for-dual-eligible-
beneficiaries.pdf on  April 21, 2014.. 

11 Kaiser Family Foundation,  Medicares Role for Dual Eligible Beneficiaries.   Accessed at 

http://www.kff.org/medicare/upload/8138-02.pdf  on November 20, 2012. 
 
12 Ibid. 

13  MMA, P.L. No. 108-173  101.  

Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 4  Marilyn Tavenner 
Medicare covers Part D plan premiums, deductibles, and other cost-sharing for dual 
eligibles up to a determined premium benchmark.  The benchmark is a statutorily defined 
amount that is based on the average premium amounts for Part D plans for each 
region.14, 15  If dual eligibles enroll in Part  D plans with premiums higher than the 
regional benchmark, they are responsible for paying the premium amounts above that 
benchmark.16    
 
Dual eligibles assignment to Part D plans.  When individuals become eligible for both 
Medicare and Medicaid, CMS randomly assigns those individuals to PDPs unless they 
have elected a specific Part D plan or have opted out of Part D prescription drug 
coverage.17  CMS assigns dual eligibles to PDPs that meet certain requirements, such as 
having a premium at or below the regional benchmark amount and offering basic 
prescription drug coverage (or equivalent).18  Basic prescription drug coverage is defined 
in terms of benefit structure (initial coverage, coverage gap, and catastrophic coverage) 
and costs (initial deductible and coinsurance). 
 
Some dual eligibles may be randomly assigned to PDPs that do not cover the specific 
drugs they use. However, unlike the general Medicare population, dual eligibles can 
switch plans at any time to find Part D plans that cover the prescription drugs they 
require.19  When dual eligibles change plans, their prescription drug coverage under their 
new Part D plans becomes effective at the beginning of the following month. 
 
CMS annually reassigns some dual eligibles to new PDPs if their current PDPs will have 
premiums above the regional benchmark premium for the following year.20  CMS 
reassigns dual eligibles who were randomly assigned to their current PDPs to new PDPs 
that will have premiums at or below the regional benchmark premium.21  In addition, 
CMS notifies dual eligibles who elected their current Part D plans that their plans will 
have premiums above the regional benchmark premium.  For 2014, CMS reported 
reassigning approximately 370,000 Medicare beneficiaries, including but not exclusively 
dual eligibles, because of premium increases.  
 
 
 
                                                 
14  42  CFR  423.780(b)(2)(i).  

15 Social Security Act,   1860D-14(a)(3)(f), 42 U.S.C.  1395w-114(a)(3)(f).  Dual eligibles residing in  

territories are not eligible to receive cost-sharing  assistance from  Medicare.  As  such, there are  no 
 
benchmarks for Part D plans offered in the territories.  

16 Patient Protection and Affordable Care Act  (ACA),  P.L. No. 111-148  3303, Social Security Act, 

  1860D 14(a)(5),  42  U.S.C.   1395w-114(a)(5).  The ACA established a de minimis premium policy, 

whereby a Part D plan may elect to charge dual eligibles the benchmark premium amount if the Part  D 

plans basic premium  exceeds the regional benchmark by a de minimis amount. For 2013, CMS set the 

de minimis amount at  $2 above the regional benchmark. 
 
17 CMS, PDBM, ch. 3,   40.1.4. 

18 Ibid.  

19 Ibid.,   30.3.2.  In  general, Medicare beneficiaries can switch Part D plans  only once a year during a 

defined enrollment period.  

20  Ibid.,  40.1.5. 
  
21  Ibid.,  40.1.5. 
  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 5  Marilyn Tavenner 
Part D Prescription Drug Coverage 
Under Part D, plans can establish formularies from which they may exclude drugs and 
control drug utilization within certain parameters.  These parameters are intended to 
balance Medicare beneficiaries needs for adequate prescription drug coverage with 
Part D plans needs to contain costs.  Generally, a formulary must include at least 
two drugs in each therapeutic category or class.22, 23  In addition, Part D plans must 
include Part D-covered drugs in certain categories and classes.24  
 
Part D plans may also control drug utilization by applying utilization management tools.  
These tools include requiring prior authorization to obtain drugs that are on plan 
formularies, establishing quantity limits, and requiring step therapy.  Utilization 
management tools can help Part D plans and the Part D program limit the cost of 
prescription drug coverage by placing restrictions on the use of certain drugs.   
 
In addition to these drug coverage decisions made regarding individual formularies, 
certain categories of drugs are excluded from Medicare Part D prescription drug coverage 
as mandated by the MMA.25  For example, prescription vitamins, prescription mineral 
products, and nonprescription drugs are excluded from Part D prescription drug 
coverage.26   
 
Until 2013, barbiturates and benzodiazepines were excluded from Part D prescription 
drug coverage. However, the ACA reversed this exclusion, removing these two drug 
types from the list of drug classes ineligible for Part D prescription drug coverage.27,  28  
 
CMS Efforts To Ensure Prescription Drug Coverage  
Formulary review. CMS annually reviews Part D plan formularies to ensure that they 
include a range of drugs in a broad distribution of therapeutic categories or classes and  
include all drugs in specified therapeutic categories or classes.29  During this review, 
CMS analyzes formularies coverage of the drug classes most commonly prescribed for 
the Medicare population. CMS intends for Part D plans to cover the most widely used 
medications, or therapeutically alternative medications (e.g., drugs from the same  
therapeutic category or class), for the most common conditions.  CMS uses Part D 
prescription drug data to identify the most commonly prescribed classes of drugs.30  
 
                                                 
22  CMS, PDBM,  ch.  6,  30.2.1.   

23 Therapeutic categories or classes classify  drugs according to their most common intended  uses.  For 
 
example, cardiovascular agents compose a therapeutic class intended to affect the rate or  intensity of  

cardiac contraction, blood  vessel diameter, or  blood volume.  

24 ACA, P.L. No. 111-148  3307, Social Security Act,  1860D  4(b)(3)(G), 42 U.S.C. 
 
 1395w-104(b)(3)(G). 

25  MMA, P.L.  No. 108-173  101, Social Security Act,  1860D-2(e), 42  U.S.C.  1395w-102(e).  

26 Social Security Act  1860D-2(e)(2), 1927(d)(2), 42  U.S.C.  1395w-102(e)(2), 1396r-8(d)(2).  

27 ACA, P.L. No. 111-148  2502, Social Security Act,  1397r-8(d).  

28 CMS, Transition to  Part D Coverage of Benzodiazepines and Barbiturates Beginning in  2013. Accessed 

at http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/ 

BenzoandBarbituratesin2013.pdf  on January 17, 2013. 

29 CMS, PDBM,  ch.  6,   30.2.1 and 30.2.5.   

30  Ibid.,  30.2.7. 
  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 6  Marilyn Tavenner 
CMS also assesses each formularys utilization management tools to ensure consistency 
with current industry standards and with standards that are widely used with drugs for the 
elderly and people with disabilities.31, 32, 33  
 
Exceptions and appeals process. CMS has implemented an exceptions and appeals 
process whereby beneficiaries can request coverage of nonformulary drugs.  
Beneficiaries apply to their Part D plans for exceptions to obtain coverage of 
nonformulary drugs.  Generally, Part D plans must make determinations within 72 hours 
or, for expedited requests, within 24 hours.34  If their plans make negative determinations, 
beneficiaries have the right to appeal.35  If their plans deny their appeals, beneficiaries 
would need to get prescriptions from their physicians for therapeutically alternative drugs 
that are covered by their plans. 
 
Transitioning new enrollees to Part D. CMS requires that Part D plans establish a 
transition process for new enrollees (including dual eligibles) who are transitioning to  
their respective Part D plans either from different Part D plans or from other prescription 
drug coverage. During Medicare beneficiaries first 90 days under a new Part D plan, the 
new plan must provide one temporary refill of a prescription when beneficiaries request 
either a drug that is not in the plans formulary or a drug that requires prior authorization 
or step therapy under the formularys utilization management tools.36  The temporary fill 
accommodates beneficiaries immediate drug needs the first time they attempt to fill a 
prescription. The transition period also allows beneficiaries time to work with their 
prescribing physicians to obtain prescriptions for therapeutically alternative drugs or to 
request formulary exceptions from Part D plans. 
 
Related OIG Work  
In 2006, OIG published a report assessing the extent to which PDP formularies included 
drugs commonly used by dual eligibles under Medicaid.  The study found that PDP 
formularies included between 76 and 100 percent of the 178 drugs commonly used by 
dual eligibles under Medicaid prior to the implementation of Part D.  Approximately half 
of the 178 commonly used drugs were covered by all formularies.37  
 
In 2011, OIG issued the first annual mandated memorandum report examining dual 
eligibles access to drugs under Medicare Part D.38  In 2012, OIG issued the second 
annual mandated memorandum report examining dual eligibles access to drugs under 
                                                 
31 CMS, PDBM, ch. 6,   30.2.2. 

32  Ibid.,  30.2.7. 
 
33 CMS looks to  appropriate guidelines from expert  organizations such as the National Committee for 

Quality Assurance, the Academy of Managed Care Pharmacy, and the National Association of Insurance 

Commissioners.  
 
34 CMS, PDBM, ch. 18,  130.1  and 130.2.  

35  Ibid.,  60.1.  

36 Ibid., ch. 6,  30.4.4.  

37 OIG,  Dual Eligibles Transition:  Part D Formularies Inclusion of  Commonly Used Drugs, 

OEI-05-06-00090, January 2006.  

38 OIG,  Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles. 

Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 7  Marilyn Tavenner 
Medicare Part D.39  In 2013, OIG issued the third annual mandated memorandum report 
examining dual eligibles access to drug under Medicare Part D.40  In the current 
memorandum report, we compare the results from 2013 and 2014. 
 
METHODOLOGY 
 
Scope 
As mandated in the ACA, this study assessed the extent to which drugs commonly used 
by dual eligibles are included by Part D plan formularies.  To make this assessment, we 
evaluated formularies for Part D plans operating in 2014.  As part of our assessment, we 
included dual eligibles enrollment data from March 2014, the most recent enrollment 
data available from CMS at the time of our study.  We also compared the results of our 
2014 study with those of our 2013 study.41    
 
The ACA did not define which drugs commonly used by dual eligibles we should review.  
We defined drugs commonly used by dual eligibles as the 200 drugs with the highest 
utilization by dual eligibles as reported in the latest Medicare Current Beneficiary Survey 
(MCBS). We used the MCBS because it contains drugs that dual eligibles received 
through multiple sources (e.g., Part D, Medicaid, and the Department of Veterans 
Affairs) and, as such, it provides a comprehensive picture of drug utilization.  Of the 
200 highest utilization drugs identified using the MCBS, 195 are eligible for coverage 
under Part D.  In this report, we refer to these 195 Part D-eligible high-utilization drugs 
as commonly used drugs. 
 
The 200 drugs with the highest utilization by dual eligibles referenced in this 
2014 memorandum report are similar but not identical to the list of drugs referenced in 
the 2013 memorandum report.  Specifically, 182 (91 percent) of the 200 drugs listed in 
the 2013 report are also listed in this 2014 report. 
 
For each study, OIG went beyond the ACAs mandate by reviewing drug coverage for all 
dual eligibles under Medicare Part D, rather than only for full-benefit dual eligibles.  
With the data available for this study, we could not confidently identify and segregate 
full-benefit dual eligiblesand thus the drugs they usedfrom the total population of 
dual eligibles.   
 
We also went beyond the ACAs mandate in both the 2013 and 2014 reports by 
examining the utilization management tools that Part D plan formularies apply to the 
drugs commonly used by dual eligibles.  These tools may affect dual eligibles access 
even in cases where formularies include the commonly used drugs.  Analyzing the extent 
to which Part D plan formularies apply these tools to drugs commonly used by dual 
eligibles allows us to provide a comprehensive picture of Part D plan formularies  
coverage of, and dual eligibles access to, those drugs. 
 
                                                 
39 OIG,  Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2012. 
40 OIG,  Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2013.  
41 Ibid. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 8  Marilyn Tavenner 
Data Sources 
MCBS.  We used 2010 MCBS Cost and Use data to create a list of the 200 drugs with the 
highest utilization by dual eligibles.  The MCBS Cost and Use data contain information 
on hospitals, physicians, and prescription drug costs and utilization.  The 2010 MCBS 
Cost and Use data are the most recent data available.   
 
The MCBS is a CMS-conducted continuous, multipurpose survey of a representative 
national sample of the Medicare population, including dual eligibles.  Sampled Medicare 
beneficiaries are interviewed three times per year and asked what drugs they are taking 
and whether they have started taking any new drugs since the previous interview.  The 
MCBS also includes Part D prescription drug events for surveyed Medicare beneficiaries.  
In 2010, the MCBS surveyed 10,741 Medicare beneficiaries, of which 2,046 were dual 
eligibles who had used prescription drugs during the year (out of 2,274 dual-eligible 
survey respondents). 
 
First Databank National Drug Data File.  We used the November 2012 and 
December 2013 First DataBank National Drug Data File to identify the drug product 
information for the 200 drugs with the highest utilization by dual eligibles.  The National 
Drug Data File is a database containing informationsuch as drug name, therapeutic 
category or class, and the unique combination of active ingredientsfor each drug 
defined by the Food and Drug Administrations National Drug Code (NDC).42  
 
Part D plan data. In November 2013 and January 2014, we collected from CMS 
formulary data and plan data for Part D plans operating in 2014.  The November 2013 
Part D formulary data include Part D plans formularies and utilization management tools 
for plans operating in 2014. In 2014, there are 329 unique formularies offered by 
3,309 Part D plans. The January 2014 Part D plan data provide information such as the 
State in which a Part D plan is offered, whether the Part D plan is a PDP or an MA-PD, 
and whether the Part D plan premium is below the regional benchmark.   
 
We also collected 2014 Part D plan enrollment data.  These data provide the number of 
dual eligibles enrolled in each Part D plan as of March 2014.    
 
Determining the Most Commonly Used Drugs 
To determine the drugs most commonly used by dual eligibles, we took the following 
steps: 
 
1. 	  Created a list of all drugs  reported by dual eligibles surveyed in the MCBS.  We  
excluded respondents from territories because they are not eligible to receive 
cost-sharing assistance under Part D. There were 150,106 drug events listed for 
2,046 MCBS-surveyed dual eligibles who did not reside in territories.43  
                                                 
42 An  NDC is a three-part universal identifier that specifies the drug manufacturers name, the drug form  
and strength, and the package size. 
43 For the purposes of this report, a drug event  is a MCBS survey response indicating that the responding  
beneficiary took a specific drug at least  once  in 2010.   For example, one MCBS survey  respondent reported 
taking atenolol 8 times in 2010.  We counted this beneficiary/drug combination as 8 drug events.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 9  Marilyn Tavenner 
2. 	  Collapsed this list to a list of drugs based on their active ingredients, using the 
Ingredient List Identifier located in First DataBanks National Drug Data File.  
For example, a multiple-source drug such as fluoxetine hydrochloride (the active 
ingredient for the multiple-source brand-name drug Prozac) has only one entry on 
our list, covering all strengths of both the brand-name drug Prozac and the generic 
versions of fluoxetine hydrochloride available.  From this point forward, unless 
otherwise stated, we will use the term drug to refer to any drug in the same  
Ingredient List Identifier category, and the term unique drug to refer to an NDC 
corresponding to a drug, as a given drug can have multiple NDCs.  This process 
left 150,106 drug events associated with 901 drugs.   
 
3. 	  Ranked the 901 drugs by frequency of utilization, weighting the drug-event 
information from MCBS by sample weight.  
 
4. 	  Selected the 200 drugs with the highest utilization by dual eligibles.  For a full list 
of the top 200 drugs, see Appendix B. 
 
5. 	  Removed all drugs not covered under Part D.  Of the 200 drugs with the highest 
utilization, 195 are eligible under Part D, 3 fell into drug categories excluded 
under Part D, 1 is no longer prescribed in the form taken by beneficiaries 
surveyed in the 2010 MCBS, and 1 is no longer available in the United States.  
For details on the five drugs excluded under Part D, see Appendix C. 
 
Formulary Analysis 
We analyzed the 329 unique Part D plan formularies to determine their rates of inclusion 
of the 195 drugs commonly used by dual eligibles.  We counted a drug as included in a 
Part D plans formulary if the formulary included the active ingredient.  When a drug 
included multiple ingredients that could be dispensed separately and combined by the  
patient to the same effect as the combined drug, we treated the drug as included if the 
ingredients were included in the formulary either separately or in combination.   
 
Low rates of inclusion by formularies.  We determined which of the 195 commonly used 
drugs had low rates of inclusion by formularies by counting how many of the 
329 formularies covered each drug.  We considered a drug to have a low rate of inclusion 
if it was included by 75 percent or less of formularies.  For such drugs, we counted the 
number of drugs (if any) that each formulary covered in the same therapeutic category or 
class. 
 
We conducted this analysis to ensure that dual eligibles have access to therapeutically 
similar drugs.  We also conducted additional research to identify potential reasons why  
some of the 195 commonly used drugs were included by less than 75 percent of 
formularies. 
 
Utilization management tools. We determined the extent  to which Part D plans apply 
utilization management tools to the 195 drugs that we reviewed.  The tools that we 
reviewed are prior authorization, quantity limits, and step therapy. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 10  Marilyn Tavenner 
To determine the extent to which the 195 commonly used drugs are subject to utilization 
management tools, we conducted an analysis of the NDCs that correspond to the 
commonly used drugs. Part D plan formularies do not apply utilization management 
tools at the active ingredient level.  Rather, Part D plan formularies apply utilization 
management tools at a more specific level that identifies whether a drug is brand-name or 
generic and its dosage form, strength, and route of administration, irrespective of package 
size. To conduct this analysis, we determined the NDCs (unique drugs) associated with 
each of the 195 commonly used drugs that are on each Part D formulary.  We then 
calculated the percentage of unique drugs to which each Part D plan formulary applies 
utilization management tools.  
 
Enrollment Analysis  
We weighted the formulary analysis by dual-eligible enrollment and weighted the 
utilization management tool analysis by both dual-eligible enrollment and Medicare 
enrollment.  To do this, we applied March 2013 enrollment data to 2013 Part D plans.   
 
Data Limitations  
We did not assess individual dual eligibles prescription drug use or whether individual 
dual eligibles are enrolled in Part D plans that include the specific drugs that each 
individual uses.  Because we relied on a sample of dual eligibles responding to the MCBS 
to develop our list of commonly used drugs, a particular dual eligible might not use any 
of the drugs on our list. However, the drugs most commonly used by dual-eligible 
MCBS survey participants in 2010 account for 87 percent of all prescriptions dispensed 
to the dual-eligible respondents in the 2010 MCBS.    
 
Because the lists of commonly used drugs in the 2013 and 2014 memorandum reports are 
not identical, changes in rates of inclusion by formularies and in application of utilization 
management tools between 2013 and 2014 may reflect changes as to which specific drugs 
were included in the lists, rather than changes regarding any specific drug.  However, the 
two lists largely overlap; 91 percent of the drugs reviewed in the 2013 report are the same  
as those reviewed in this 2014 report. 
 
Standards 
This study was conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
RESULTS  
 
Part D Plan Formularies Include Between 86 and 100 Percent of the Drugs 
Commonly Used by Dual Eligibles  
On average, Part D plan formularies include 96 percent of the drugs commonly used by 
dual eligibles. Of the 329 unique formularies used by Part D plans in 2014, 
18 formularies include 100 percent of the commonly used drugs.  At the other end of the 
inclusion range, three formularies include 86 percent of the commonly used drugs.  CMS 
generally requires Part D plan formularies to include at least two drugs, rather than all 
drugs, in each therapeutic category or class.  Therefore, Part D plan formularies may still 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 11  Marilyn Tavenner 
meet CMSs formulary requirements even if they do not include all of the drugs we 
identified as commonly used by dual eligibles. 
 
Part D plan formularies inclusion of the drugs commonly used by dual eligibles in 2014 
is nearly identical to that of 2013. The average rate of inclusion96 percentwas 
unchanged between 2013 and 2014. The ranges of inclusion in 2013 and 2014 are almost 
the samein 2013, the rates of inclusion ranged from 85 to 100 percent of the drugs 
commonly used by dual eligibles, and in 2014, they ranged from 86 to 100 percent. 
 
Nationally, PDP and MA-PD formularies include a similar average of the drugs 
commonly used by dual eligibles: 94 percent and 96 percent, respectively.  PDP 
formularies rates of inclusion of the commonly used drugs ranged from 86 to 
100 percent and MA-PD formularies rates ranged from 87 to 100 percent.  Twenty-one 
formularies6 percent of the 329 unique formularies used by Part D plans in 2014are 
offered by both PDPs and MA-PDs. 
 
Regionally, all dual eligibles have the choice of a Part D plan that includes at least 
98 percent of the commonly used drugs. Every PDP region has a plan that includes at 
least 99 percent of the commonly used drugs, and every MA-PD region has a plan that 
covers at least 98 percent of these drugs.  Appendix D provides a breakdown of 
formulary inclusion by PDP and MA-PD region. 
 
On average, formularies for Part D plans with premiums below the regional benchmark 
include 95 percent of the drugs commonly used by dual eligibles. The percentage of 
drugs included by Part D plans with premiums below the regional benchmark is 
important because dual eligibles are automatically enrolled in, or annually reassigned to, 
these plans. For drugs commonly used by dual eligibles, formularies for Part D plans  
with premiums below the regional benchmark have a rate of inclusion that ranges from 
86 percent to 100 percent. Approximately 83 percent of dual eligibles are enrolled in 
Part D plans with premiums  below the regional benchmark. 
 
Ninety-nine percent of dual eligibles are enrolled in Part D plans that include at least 
90 percent of the drugs commonly used by dual eligibles. Of the approximately 
9.5 million dual eligibles enrolled in Part D plans, 99 percent are enrolled in Part D plans 
that use formularies that include at least 90 percent of the commonly used drugs.  Only 
1 percent of dual eligibles are enrolled in Part D plans that use formularies that include 
less than 90 percent of these drugs. Table 1 provides a breakdown of dual eligibles 
enrollment in Part D plans by the plans formulary inclusion rates. 
 
   
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 12  Marilyn Tavenner 
Table 1: Enrollment of Dual Eligibles in Part D Plans and Formulary  
Inclusion of Commonly  Used Drugs  
 
Part D Plans With Formularies That  Number of Dual   Percentage of Dual 
Include:   Eligibles Enrolled*  Eligibles Enrolled  
100% of commonly  used drugs   172,000   2%  
95% to 99% of commonly used drugs  3,453,000   36%  
90% to 94% of commonly used drugs  5,745,000   61%  
85% to 89% of commonly used drugs  120,000   1% 
     Total   9,490,000   100%  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles and dual  eligibles 

enrollment, 2014. 

*Rounded to  the nearest 1,000. 

 
The percentage of dual eligibles enrolled in Part D plans that include at least 90 percent 
of the drugs commonly used by dual eligibles stayed consistent between 2013 and 2014 
at 99 percent.    
 
Sixty-Four Percent of the Drugs Commonly Used by Dual Eligibles Are Included in 
All Part D Plan Formularies  
Because most of the commonly used drugs are included in a large percentage of 
formularies, dual eligibles are guaranteed that, regardless of the Part D plan in which they 
are enrolled, the plans formulary will include many of these drugs.  By drug, formulary 
inclusion ranges from 45 percent to 100 percent.  In other words, one drug commonly 
used by dual eligibles is included in as few as 45 percent of Part D plan formularies, and 
125 drugs are included in all plan formularies.  The average rate of inclusion by 
formularies is 96 percent.  Table 2 provides a summary of rates of inclusion by 
formularies.  Appendix B provides rates of inclusion by formularies for each of the 
commonly used drugs. 
 
Table 2: Formularies Rates of Inclusion of Commonly Used Drugs  
Percentage of the 195 Commonly  
Percentage of the 329 Formularies  Used Drugs Included in 
Formularies  
64%  
100%  
(125 drugs)  
25%  
85% to 99%  
(48 drugs)  
6%  
75% to 84%  
(11 drugs)  
6%  
45% to 74%  
(11 drugs) 
100%*  
 Total  
(195 drugs)  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles, 2014. 
 
* Percentages do not add to 100 percent because of rounding. 
 
The rates of formulary inclusion of the drugs commonly used by dual eligibles in 2014 
are similar to those in 2013.  The percentage of commonly used drugs included in all 
formularies  remained the same between 2013 and 2014, at 64 percent. 
 
   
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 13  Marilyn Tavenner 
Part D plan formularies include certain drugs less frequently than others. Of the 
commonly used drugs, 6 percent (11 drugs) are included by less than 75 percent of Part D 
plan formularies.  Table 3 provides the percentage of formularies covering each of these 
11 drugs. 
 
The drugs that make up this group include both brand and generic drugs, and are used to 
treat a variety of primary indications.  Five of the eleven drugs are brand-name drugs, 
which are typically more costly than generic drugs.  In terms of primary indications, 3 of 
the 11 drugs are muscle relaxants, and the remaining drugs treat a variety of conditions  
including high cholesterol, anxiety, and insomnia.  
 
Table 3: Drugs Included by Less Than 75 Percent of Part D Plan Formularies  
Rate of  
Generic Name of Drug   Primary Indication(s)   Inclusion by  
Formularies  
Promethazine HCL   Allergies   71%  
Valsartan*   Hypertension (high blood pressure)   71%  
Temazepam*   Insomnia  65%  
Ezetimibe/simvastatin*   Hyperlipidemia (high cholesterol)   64%  
Methocarbamol*   Muscle relaxant   64%  
Dyspepsia, peptic ulcer disease, gastroesophageal reflux 
Esomeprazole magnesium*   62%  
disease, Zollinger-Ellison syndrome  
Cyclobenzaprine HCL*   Muscle relaxant   59%  
Hydroxyzine pamoate   Anxiety   54%  
Hydrocortisone acetate  Hemorrhoids  51%  
Carisoprodol*   Muscle relaxant   47%  
Darifenacin hydrobromide   Overactive bladder   45%  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles, 2014. 
* These drugs also  had low formulary inclusion rates in 2013.  
 
Although Part D formularies frequently omit these 11 drugs, they all cover other drugs in 
the same therapeutic classes.  For these 11 drugs, 100 percent of formularies cover at 
least 1 drug in the same therapeutic class that is also on the list of 195 drugs commonly 
used by dual eligibles. 
  
The number of drugs included by less than 75 percent of formularies  decreased from  
16 in 2013 to 11  in 2014.  There are seven  drugs with low inclusion rates in 2014 that 
were also on the list of commonly used drugs with low inclusion rates in our 2013 report; 
these drugs are noted in Table 3.  Three of the low-inclusion drugs were also listed as 
low-inclusion drugs in our 2012 report.  
 
There are many potential reasons why a commonly used drug might be included by less 
than 75 percent of formularies: 
 
 	  Seven of these drugscarispoprodol, cyclobenzaprine HCl, darifenacin 
hydrobromide, hydroxyzine pamoate, methocarbamol, promethazine HCL, 
temazepamare listed as being potentially inappropriate for older adults. 
   
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 14  Marilyn Tavenner 
 	  Further, two of these drugscyclobenzaprine HCl and methocarbamolare on 
CMSs list of high-risk Part D medications, which may explain the low inclusion 
rates for these drugs.44     
	   Another drugtemazepamis a benzodiazepine, a category of drugs that was 
excluded from Part D coverage until 2013.  Temazepam was also on the list of 
drugs with low inclusion by formularies in 2013 report.  The low inclusion rates 
for temazepam may be explained by CMSs change in Part D coverage 
guidelines. 
 
Low rates of inclusion by formularies may require dual eligibles to obtain a nonformulary 
drug. There are several means by which dual eligibles can obtain a nonformulary drug, 
all of which require them to take additional action.  Obtaining therapeutically alternative 
drugs requires that dual eligibles get new prescriptions from  their doctors.  Dual eligibles 
may also submit statements of medical necessity from their physicians as part of appeals 
to obtain coverage of nonformulary drugs.45  Finally, dual eligibles may switch to Part D 
plans that include their drugs, with the new coverage becoming effective the following 
month.46  
 
The Percentage of Commonly Used Drugs Subject to Utilization Management Tools 
by Plan Formularies Remained the Same Between 2013 and 2014 
For the unique drugs that compose the list of commonly used drugs, the percentage 
subject to utilization management tools by Part D plan formularies remained the same 
with an average of 28 percent in both 2013 and 2014.  Formularies for plans with 
premiums below the regional benchmarks and for plans with premiums above the 
benchmarks had the same percentage of drugs28 percentthat were subject to 
utilization management tools.  See Table 4 for a breakdown of the percentage of unique 
drugs to which Part D plan formularies apply utilization management tools in 2013 and 
2014. 
   
                                                 
44 This listUse of High-Risk Medications in the Elderly:   High-Risk Medications is part of the  
Healthcare Effectiveness and  Information Set national  drug code  measures published by  the National  
Committee for Quality Assurance.  A high-risk medication is a drug with a high  risk  of serious side effects 
in the elderly.  CMS uses this medication list to calculate the percentage of Medicare beneficiaries who 
received at least one high-risk medication in the past year.  CMS publishes this percentage and other Part D 
patient safety measures so that Medicare beneficiaries can make informed decision in choosing a Part D 
plan  for their prescription drug coverage.  National Committee on  Quality Assurance, HEDIS 2012  NDC 
List. Accessed at http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2012/  
HEDIS2012FinalNDCLists.aspx on  January 14, 2013 and at http://www.cms.gov/Medicare/Prescription-
Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Technical-Notes-2013-.pdf on  March 25, 2013. 
45 CMS, PDBM, ch. 18,  30.2.2.  
46 CMS, PDBM, ch. 3,   30.3.2. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 15  Marilyn Tavenner 
 
Table 4: Part D Plan Formularies Application of Utilization Management Tools to 
Commonly  Used Drugs, 2013 to 2014  
Percentage of Unique Drugs   Number of   Percentage of   Number of   Percentage of  
to Which Utilization  2013 Part D  2013 Part D  2014 Part D  2014 Part D 
Management Tools Are  Plan  Plan  Plan  Plan 
Applied  Formularies   Formularies   Formularies   Formularies  
Greater than 40%   41  13%   30  9%  
30% to 39%   116  38%   136  41%  
20% to 29%   74  25%   65  20%  
10% to 19%   34  11%   75  23%  
Less than 10%   37  12%   23  7% 
     Totals   302  100%*   329  100%  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles, 2014. 
* Percentages do not add to 100 percent because of rounding. 
 
In 2014, the percentage of drugs subject to quantity limits remained essentially the same 
while there was a slight decrease in the percentage of drugs subject to prior authorization 
or step therapy. Formularies applied quantity limits to 24 percent of unique drugs in both 
2013 and 2014. Formularies decreased the use of prior authorization from 5 percent to 
3 percent and decreased the use of step therapy from 3 percent to 2 percent.  
 
The rate at which plan formularies apply specific utilization management tools varies 
widely.  In 2014, some formularies applied utilization management tools to none of the 
unique drugs, whereas at the other end of the range, some applied tools to 45 percent of 
the unique drugs. More specifically, formularies apply quantity limits to 043 percent of 
unique drugs, prior authorization to 09 percent, and step therapy to 016 percent.   
 
Looking at enrollment across plans provides a slightly different picture than looking only 
at plans themselves.  On average, plan formularies in 2014 apply utilization management 
tools to 28 percent of unique drugs. However, dual eligiblesand the Medicare 
population as a wholetend to be enrolled in plans with formularies that apply these 
tools at a higher rate. When plans are weighted by dual-eligible enrollment, the median 
plan applies such tools to 34 percent of unique drugs, a slight decrease from the 2013 rate 
of 35 percent. Similarly, when plans are weighted by overall Medicare enrollment, the 
median plan applies these tools to 33 percent of unique drugs in 2014, a slight increase 
from 32 percent in 2013.   
 
Both dual eligibles and Medicare beneficiaries overall tend to be enrolled in plans with 
formularies that apply utilization management tools to between 30 and 45 percent of 
unique drugs. In 2013, 68 percent of dual eligibles and 58 percent of Medicare 
beneficiaries overall were enrolled in plans with formularies in this range.  Table 5 
provides a breakdown of dual eligibles and Medicare beneficiaries enrollment in Part D 
plans by the percentage range of unique drugs to which formularies apply utilization 
management tools.   
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 16  Marilyn Tavenner 
Table 5: Beneficiary Enrollment in Part D Plans by Application of Utilization 
Management Tools to Commonly Used Drugs, 2013 to 2014  
Percentage of   Percentage of  
Percentage of Unique Drugs to   Percentage of   Percentage of  
Medicare  Medicare 
Which Plan Formularies Apply   Dual Eligibles  Dual Eligibles 
Beneficiaries  Beneficiaries 
Utilization Management Tools   Enrolled, 2013   Enrolled, 2014  
Enrolled, 2013   Enrolled, 2014  
Greater than 40%   18%   20%   5%   14%  
30% to 39%   44%   34%   63%   44%  
20% to 29%   16%   12%   7%   6%  
10% to 19%   6%   5%   24%   32%  
Less than 10%   17%   29%   2%   4% 
     Totals   100%*   100%   100%*   100%  
Source:  OIG analysis of dual-eligible enrollment and Medicaid  beneficiary enrollment by rates of utilization management tool 
 
application to drugs commonly used by dual eligibles, 2014. 

*Percentages do not add to 100 percent because of rounding. 
 
 
Further, although utilization management tools control access to drugs, they are 
important tools for managing costs in Medicare and ensuring appropriate utilization of  
drugs. For example, oxycodone HCl/acetaminophen drugs saw more than a 30-percent 
increase in formulary application of utilization management controls in 2013.  Such 
limits may be intended to ensure appropriate utilization, as CMSs Part D 2013 guidance 
to Part D sponsors set forth expectations for opioid overutilization reviews to help ensure 
that opioids are prescribed and used correctly.47  
 
CONCLUSION 
 
When establishing formularies and applying utilization management tools, Part D plans 
need to balance Medicare beneficiaries needs for adequate prescription drug coverage 
with the need to contain costs for themselves and for the Part D program.  By law, Part D 
plan formularies do not have to include every available drug.  Rather, to meet CMSs  
formulary requirements, they must include at least two drugs in each therapeutic category 
or class. For example, for each of the 11 drugs that this memorandum report identifies as 
being included by less than 75 percent of Part D plan formularies, all Part D plan 
formularies cover at least one therapeutically alternative drug.  Part D plan formularies 
may also institute utilization management tools to ensure appropriate utilization as well 
as to control costs.  
 
For the drugs commonly used by dual eligibles, we found that the rate of formulary 
inclusion is high with some variation.  On average, Part D plan formularies include 
96 percent of the commonly used drugs. Part D plan formularies inclusion of the 
commonly used drugs ranges from 86 percent to 100 percent.  Formulary inclusion rates 
are similar for PDPs and MA-PDs.  Further, formularies for Part D plans with premiums  
below the regional benchmark include the commonly used drugs at a rate similar to that 
of Part D plan formularies overall. 
 
                                                 
47 CMS, Supplemental Guidance Related to  Improving Drug Utilization Review Controls in  Part D.  
Accessed at http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/  
Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf  on January 16, 2013. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 17  Marilyn Tavenner 
Inclusion rates for the 195 drugs commonly used by dual eligibles are largely unchanged 
compared with those from OIGs 2013 memorandum report.  Part D plan formularies 
include roughly the same percentage of these commonly used drugs in 2014 as they did 
in 2013. Enrollment in plans that cover at least 90 percent of unique drugs stayed 
consistent, with 99 percent of dual eligibles enrolled in such plans.     
 
Because some variation exists in Part D plan formularies inclusion of the commonly 
used drugs and in their application of utilization management tools to these drugs, some 
dual eligibles may need to use alternative methods to access the drugs they take.  They 
could appeal prescription drug coverage decisions, switch prescription drugs, or switch 
Part D plans. These scenarios require additional effort by dual eligibles and may result in 
administrative barriers to accessing certain prescription drugs. 
 
As mandated by the ACA, OIG will continue to monitor the extent to which Part D plan 
formularies cover drugs that dual eligibles commonly use.  In addition, OIG will continue 
to monitor Part D plan formularies application of utilization management tools to these 
drugs. 
 
This memorandum report is being issued directly in final form because it contains no 
recommendations.  We have included the list of the 200 drugs with the highest utilization 
by dual eligibles. If you have comments or questions about this report, please provide 
them within 60 days.  Please refer to report number OEI-05-14-000170 in all 
correspondence. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 18  Marilyn Tavenner 
APPENDIX A 
 
Section 3313 of the Patient Protection and Affordable Care Act of 2010 
 
SEC. 3313.  OFFICE OF THE INSPECTOR GENERAL STUDIES AND REPORTS. 
 
(a)  STUDY AND ANNUAL REPORT ON PART D FORMULARIES INCLUSION 
OF DRUGS COMMONLY USED BY DUAL ELIGIBLES.  
 
(1) STUDY.The Inspector General of the Department of Health and Human Services 
shall conduct a study of the extent to which formularies used by prescription drug plans 
and MA-PD plans under Part D include drugs commonly used by full benefit dual 
eligible individuals (as defined in section 1935(c)(6) of the Social Security Act 
(42 U.S.C. 1396u5(c)(6)). 
 
(2)  ANNUAL REPORTS.Not later than July 1 of each year (beginning with 2011), the 
Inspector General shall submit to Congress a report on the study conducted under 
paragraph (1), together with such recommendations as the Inspector General determines 
appropriate. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 19  Marilyn Tavenner 
APPENDIX B  
 
Commonly Used Drugs and Rates of Formulary Inclusion 
 
Table B-1: 200 Drugs With the Highest Utilization by Dual Eligibles   
Projected   Number of   Percentage of  
Sample  95-Percent Confidence 
Generic Name   Number of   Formularies  Formularies 
Size*  Interval*  
Scripts*   Including   Including  
Lisinopril  4,049   17,526,086   15,331,76519,720,406   329  100%  
Simvastatin  3,908   16,947,357   15,003,27818,891,435   328  100%  
Furosemide  3,706   14,685,813   13,216,52116,155,104   329  100%  
Hydrocodone 
Bit/Acetaminophen  4,001   14,666,041   13,199,67316,132,409   329  100%  
Omeprazole  3,671   14,385,881   12,805,02415,966,738   329  100%  
Levothyroxine sodium  3,342   13,657,429   12,044,45515,270,403   329  100%  
Potassium chloride  2,890   11,003,461   9,736,33712,270,585   329  100%  
Amlodipine besylate  2,592   10,969,140   9,475,67412,462,606   329  100%  
Metformin HCl   2,483   10,431,797   8,979,26511,884,328   329  100%  
Warfarin sodium   2,508   10,037,136   8,168,68211,905,591   329  100%  
Metoprolol tartrate   2,142   8,581,675   7,404,3969,758,953  329  100%  
Atorvastatin calcium  1,713   6,979,616   5,816,2248,143,007  329  100%  
Atenolol  1,576   6,864,054   5,736,8727,991,236  329  100%  
Clopidogrel bisulfate  1,506   6,522,574   5,481,1667,563,982  329  100%  
Esomeprazole magnesium  1,485   6,343,762   5,215,7047,471,819  203  62%  
Hydrochlorothiazide  1,431   6,307,800   5,263,0817,352,520  329  100%  
Gabapentin  1,622   6,059,703   4,960,8767,158,530  329  100%  
Albuterol sulfate  1,341   5,303,805   4,497,2906,110,319  329  100%  
Carvedilol  1,174   5,049,410   4,177,6125,921,208  327  99%  
Zolpidem tartrate   1,224   4,983,444   4,152,0915,814,797  325  99%  
Glipizide  1,146   4,822,133   3,980,4825,663,783  329  100%  
Citalopram hydrobromide   1,310   4,783,877   3,913,1825,654,572  329  100%  
Alendronate sodium  948  4,614,027   3,660,6535,567,401  329  100%  
Sertraline HCl   1,261   4,559,228   3,801,8695,316,588  329  100%  
Ranitidine HCl  1,262   4,455,550   3,592,4885,318,613  329  100%  
Trazodone HCl   1,174   4,391,732   3,430,1345,353,330  329  100%  
Oxycodone 
HCl/acetaminophen  1,267   4,276,243   3,399,3595,153,128  329  100%  
Metoprolol succinate  941  4,184,076   3,375,4984,992,654  324  98%  
Quetiapine fumarate  1,523   4,095,070   3,274,7704,915,371  329  100%  
Rosuvastatin calcium   852  3,974,567   3,044,1034,905,030  290  88%  
Fluticasone/salmeterol  878  3,949,321   3,178,8464,719,796  317  96%  
Risperidone  1,209   3,932,051   3,058,9804,805,122  329  100%  
Tramadol HCl  1,112   3,877,159   3,152,1984,602,120  329  100%  
Donepezil HCl  1,138   3,759,718   3,126,2124,393,224  329  100%  
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 20  Marilyn Tavenner 
Table B-1: 200 Drugs With the Highest Utilization by Dual Eligibles, continued  
Projected   Number of   Percentage of  
Sample  95-Percent Confidence 
Generic Name   Number of   Formularies  Formularies 
Size*  Interval*  
Scripts *   Including   Including  
Insulin glargine,hum.rec.anlog   851  3,659,644   3,012,3094,306,978  314  95%  
Fluticasone propionate   865  3,597,277   2,821,4804,373,073  329  100%  
Divalproex sodium   1,020   3,542,033   2,061,5025,022,565  329  100%  
Pioglitazone HCl  804  3,437,272   2,640,5534,233,992  329  100%  
Isosorbide mononitrate   816  3,388,631   2,674,5544,102,707  329  100%  
Valsartan  766  3,383,711   2,649,1284,118,294  232  71%  
Prednisone  888  3,364,367   2,692,7724,035,963  329  100%  
Montelukast sodium  824  3,340,768   2,506,4964,175,041  329  100%  
Cyclobenzaprine HCl  784  3,338,445   2,715,5743,961,316  195  59%  
Diltiazem HCl  763  3,301,378   2,498,8844,103,872  329  100%  
Duloxetine HCl  586  3,260,018   533,2485,986,789  329  100%  
Pravastatin sodium  738  3,245,987   2,495,6523,996,321  329  100%  
Escitalopram oxalate  980  3,108,921   2,491,9933,725,848  328  100%  
Lovastatin  645  2,874,074   2,214,7913,533,357  326  99%  
Tamsulosin HCl  696  2,800,208   2,150,8013,449,615  329  100%  
Tiotropium bromide  577  2,784,574   2,210,0133,359,135  322  98%  
Clonidine HCl  726  2,733,778   2,159,0823,308,475  329  100%  
Digoxin  736  2,733,625   2,033,2963,433,954  329  100%  
Ibuprofen  764  2,718,286   2,101,3093,335,262  329  100%  
Glimepiride  538  2,659,533   2,062,0793,256,986  329  100%  
Paroxetine HCl   600  2,646,915   1,947,3653,346,465  329  100%  
Allopurinol  682  2,601,275   1,988,9003,213,650  329  100%  
Lisinopril/hydrochlorothiazide  564  2,555,824   1,889,1013,222,547  328  100%  
Azithromycin  668  2,525,071   2,168,8232,881,320  329  100%  
Enalapril maleate  633  2,514,748   1,861,6703,167,826  329  100%  
Pantoprazole sodium  583  2,457,619   1,811,7253,103,513  328  100%  
Clonazepam  651  2,382,146   1,730,5023,033,790  329  100%  
Mirtazapine  721  2,367,499   1,887,6492,847,349  329  100%  
Memantine HCl   719  2,362,226   1,788,2322,936,221  329  100%  
Venlafaxine HCl   595  2,326,346   1,433,2933,219,400  329  100%  
Meloxicam  511  2,291,140   1,806,5162,775,764  328  100%  
Naproxen  606  2,254,503   1,719,2982,789,707  329  100%  
Famotidine  565  2,194,121   1,620,5762,767,667  327  99%  
Nifedipine  533  2,193,852   1,585,6212,802,083  327  99%  
Alprazolam  651  2,190,069   1,753,3852,626,753  248  75%  
Carbamazepine  621  2,169,900   1,475,4622,864,338  329  100%  
Spironolactone  472  2,143,185   1,622,9252,663,444  329  100%  
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 21  Marilyn Tavenner 
Table B-1: 200 Drugs With the Highest Utilization by Dual Eligibles, continued  
Projected   Number of   Percentage of  
Sample  95-Percent Confidence 
Generic Name   Number of   Formularies  Formularies 
Size*  Interval*  
Scripts *   Including   Including  
Fluoxetine HCl  553  2,094,592   1,455,6022,733,581  329  100%  
Pregabalin  636  2,086,857   1,581,6852,592,029  329  100%  
Fexofenadine HCl  580  2,082,626   1,545,8922,619,361     
Propoxyphene napsylate 
/acetaminophen  604  2,082,433   1,694,9042,469,963     
Valsartan/ 
hydrochlorothiazide  481  2,069,464   1,412,1892,726,738  316  96%  
Promethazine HCl  607  2,021,571   1,703,7722,339,370  234  71%  
Oxycodone HCl   617  2,008,292   1,342,4482,674,137  328  100%  
Glyburide  483  1,975,413   1,447,1012,503,725  280  85%  
Aripiprazole  731  1,970,998   1,465,9752,476,021  329  100%  
Morphine sulfate   599  1,931,038   1,160,3692,701,707  329  100%  
Nitroglycerin  496  1,900,437   1,411,0562,389,818  329  100%  
Amitriptyline HCl  538  1,882,663   1,338,7732,426,552  329  100%  
Ipratropium/albuterol sulfate  438  1,876,353   1,357,1552,395,551  321  98%  
Sitagliptin phosphate  404  1,867,218   1,297,7832,436,654  316  96%  
Lorazepam  514  1,852,994   1,283,3032,422,684  311  95%  
Ciprofloxacin HCl  511  1,847,320   1,555,6682,138,973  329  100%  
Cephalexin  527  1,808,242   1,481,7562,134,727  329  100%  
Meclizine HCl  462  1,801,969   1,312,9522,290,986  319  97%  
Bupropion HCl   509  1,793,546   1,281,8072,305,286  329  100%  
Triamterene/  
hydrochlorothiazid  391  1,776,758   1,253,0012,300,515  329  100%  
Fenofibrate nanocrystallized   404  1,775,090   1,214,0012,336,179  313  95% 
Sulfamethoxazole/ 
trimethoprim  523  1,764,454   1,458,8822,070,025  329  100%  
Losartan potassium  380  1,764,440   1,222,1432,306,737  329  100%  
Oxybutynin chloride  480  1,740,865   1,345,6342,136,096  329  100%  
Verapamil HCl  346  1,703,733   1,230,3382,177,127  329  100%  
Lansoprazole  380  1,683,504   1,211,1292,155,880  263  80%  
Diclofenac sodium   405  1,648,570   1,164,6862,132,454  329  100%  
Lidocaine  466  1,636,160   1,177,1282,095,192  329  100%  
Latanoprost  404  1,628,021   1,152,8932,103,149  329  100%  
Amoxicillin  418  1,606,735   1,358,3881,855,083  329  100% 
Ezetimibe  364  1,592,702   1,118,1472,067,257  329  100%  
Benztropine mesylate   549  1,590,165   1,078,7612,101,568  325  99%  
Fentanyl  423  1,590,156   872,0092,308,303  329  100%  
Levofloxacin  431  1,561,579   1,233,3021,889,856  329  100%  
Insulin aspart  400  1,521,854   1,143,8251,899,883  277  84%  
Tolterodine tartrate  393  1,517,053   1,097,9021,936,203  312  95%  
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 22  Marilyn Tavenner 
Table B-1: 200 Drugs With the Highest Utilization by Dual Eligibles, continued  
Projected   Number of   Percentage of  
Sample  95-Percent Confidence 
Generic Name   Number of   Formularies  Formularies 
Size*  Interval*  
Scripts*   Including   Including  
Carisoprodol  416  1,501,274   968,7662,033,783  153  47%  
Insulin regular, human   389  1,494,291   1,031,6441,956,937  329  100%  
Levetiracetam  502  1,473,031   998,0501,948,011  329  100%  
Albuterol  396  1,472,047   792,7762,151,318     
Olanzapine  505  1,432,551   981,4911,883,610  329  100%  
Mometasone furoate  377  1,422,774   980,0631,865,484  328  100%  
Doxazosin mesylate  307  1,421,563   963,2271,879,900  329  100%  
Celecoxib  312  1,420,857   997,3471,844,367  291  88%  
Ezetimibe/simvastatin  285  1,398,142   894,0581,902,227  210  64%  
Amlodipine 
besylate/benazepril  278  1,384,176   971,8901,796,462  317  96%  
Lactulose  408  1,380,890   932,9731,828,808  329  100%  
Phenytoin sodium extended   427  1,375,442   973,5701,777,314  329  100%  
Benazepril HCl  312  1,367,757   857,3181,878,195  328  100%  
Ramipril  293  1,362,475   759,5581,965,391  325  99%  
Finasteride  287  1,352,674   966,7731,738,576  329  100%  
Triamcinolone acetonide  363  1,338,148   1,015,0941,661,201  329  100%  
Hum Insulin Nph/Reg Insulin 
Hm  374  1,328,419   979,0591,677,779  329  100%  
Hydroxyzine HCl   333  1,322,202   755,7361,888,668  273  83%  
Ropinirole HCl   298  1,287,497   760,6431,814,352  329  100%  
Hydralazine HCl  336  1,251,590   863,4161,639,764  329  100%  
Polyethylene glycol 3350  404  1,248,600   909,7371,587,464  322  98%  
Buspirone HCl   334  1,240,126   793,8761,686,376  329  100%  
Estrogens, conjugated   291  1,235,655   832,3191,638,991  325  99%  
Terazosin HCl   297  1,208,995   812,2201,605,771  329  100%  
Metoclopramide HCl  309  1,193,673   805,0301,582,317  329  100%  
Brimonidine tartrate  263  1,173,338   775,4501,571,225  329  100%  
Carbidopa/levodopa  366  1,155,427   730,6561,580,198  329  100%  
Lamotrigine  436  1,129,854   795,9061,463,802  329  100%  
Baclofen  381  1,128,460   756,3681,500,552  329  100%  
Propranolol HCl   312  1,109,568   774,3001,444,835  329  100%  
Ziprasidone HCl   502  1,107,688   705,1451,510,231  329  100%  
Diazepam  317  1,092,935   670,9551,514,914  329  100%  
Risedronate sodium  269  1,087,393   730,3921,444,394  247  75%  
Omega3 acid ethyl esters   243  1,072,683   510,1791,635,187  306  93%  
Topiramate  426  1,030,993   649,8341,412,152  329  100%  
Methocarbamol  269  1,017,362   505,4951,529,228  210  64%  
Clotrimazole/betamethasone 
dip  282  1,010,615   635,1911,386,040  288  88%  
Methylprednisolone  244  993,034   659,5111,326,556  329  100%  
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 23  Marilyn Tavenner 
Table B-1: 200 Drugs With the Highest Utilization by Dual Eligibles, continued  
Projected   Number of   Percentage of  
Sample  95-Percent Confidence 
Generic Name   Number of   Formularies  Formularies 
Size*  Interval*  
Scripts*   Including   Including  
Ipratropium bromide  247  975,326   594,8371,355,814  329  100%  
Gemfibrozil  316  962,455   615,7231,309,188  329  100%  
Glyburide/metformin HCl  205  950,386   625,4581,275,314  276  84%  
Acetaminophen with codeine   265  948,099   720,8581,175,340  329  100%  
Nystatin  280  946,856   694,6581,199,055  329  100%  
Amoxicillin/potassium 
clavulanate  266  906,325   713,8481,098,802  329  100%  
Ketoconazole  236  893,572   517,1291,270,015  329  100%  
Amiodarone HCl  221  882,707   532,8451,232,568  329  100%  
Folic acid   215  870,744   580,3271,161,162     
Temazepam  209  870,741   536,7891,204,692  214  65%  
Doxycycline hyclate  266  863,594   671,3931,055,796  329  100%  
Niacin  221  854,672   490,1131,219,231  329  100%  
Sucralfate  217  854,101   511,0841,197,117  329  100%  
Pramipexole DiHCl  187  850,734   436,1281,265,340  329  100%  
Neutrap protamine hagedorn, 
human insulin isophane   207  841,706   553,2171,130,196  329  100%  
Insulin detemir  181  838,194   523,2731,153,115  320  97%  
Oxcarbazepine  285  822,165   477,9511,166,378  329  100%  
Nitrofurantoin monohydrate/  
macrocrystals  204  806,300   541,1671,071,433  309  94%  
Solifenacin succinate  171  795,224   428,3611,162,087  271  82%  
Hydroxyzine pamoate   212  794,850   378,7381,210,961  177  54%  
Dicyclomine HCl   205  761,078   474,7311,047,425  267  81%  
Metolazone  200  754,643   489,7751,019,510  321  98%  
Budesonide/formoterol 
fumarate  182  739,927   503,057976,797  292  89%  
Darifenacin hydrobromide   178  729,078   418,0901,040,066  149  45%  
Bimatoprost  140  726,619   422,2021,031,037  290  88%  
Hydrocortisone acetate  141  722,972   361,6141,084,330  167  51%  
Ergocalciferol (Vitamin D2)   199  722,170   452,905991,434     
Nabumetone  171  720,777   453,343988,210  321  98%  
Isosorbide dinitrate  147  719,742   323,2961,116,188  329  100%  
Torsemide  165  710,217   291,4041,129,030  321  98%  
Olopatadine HCl  186  707,858   417,593998,124  284  86%  
Lithium carbonate  221  705,974   384,9071,027,041  329  100%  
Timolol maleate  203  703,462   452,117954,807  329  100%  
Tizanidine HCl  284  702,405   440,132964,678  329  100%  
Irbesartan/  
hydrochlorothiazide  128  692,517   322,7541,062,280  282  86%  
Dutasteride  134  690,427   364,9541,015,900  299  91%  
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 24  Marilyn Tavenner 
Table B-1: 200 Drugs With the Highest Utilization by Dual Eligibles, continued  
Projected   Number of   Percentage of  
Sample  95-Percent Confidence 
Generic Name   Number of   Formularies  Formularies 
Size*  Interval*  
Scripts*   Including   Including  
Fluconazole  204  681,807   532,325831,289  329  100%  
Travoprost  194  681,615   470,043893,187  278  84%  
Ibandronate sodium  130  681,499   339,5831,023,415  317  96%  
Estradiol  121  680,842   341,2341,020,449  329  100%  
Losartan/hydrochlorothiazide  146  661,914   362,115961,712  328  100%  
Cinacalcet HCl  171  661,514   343,657979,372  329  100%  
Haloperidol  257  652,766   427,602877,930  329  100%  
Aspirin/dipyridamole  162  651,442   334,771968,114  328  100%  
Raloxifene HCl  138  650,060   267,5831,032,537  329  100%  
Medroxyprogesterone 
acetate  131  646,445   316,771976,120  329  100%  
Megestrol acetate  161  611,738   387,587835,890  329  100%  
Labetalol HCl  146  603,265   292,698913,832  329  100%  
Fenofibrate  131  597,584   365,922829,245  328  100%  
Calcitriol  135  587,342   316,836857,847  329  100%  
Metronidazole  157  585,344   407,663763,025  329  100%  
Clozapine  181  582,542   145,2631,019,820  329  100%  
Insulin lispro  160  579,111   334,382823,840  264  80%  
Diphenoxylate HCl/atropine   132  573,335   241,642905,028  250  76%  
Sotalol HCl  130  550,800   174,131927,469  329  100%  
Source:  OIG analysis of drugs commonly used by dual eligibles, 2014. 

*Sample is from the 2010 Medicare Current Beneficiary Survey.  Projections and confidence intervals are derived from its survey 
 
methodology. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 25  Marilyn Tavenner 
APPENDIX C 
 
Five Drugs Commonly Used by Dual Eligibles and Not Covered Under Part D 
 
Generic Name   Reason Excluded Under Part D  
No longer prescribed without 
Albuterol* 
sulfate 
Fexofenadine HCl*  Nonprescription drug  
Folic acid*   Vitamin or mineral product  
Propoxyphene  No longer available in the United 
napsylate/acetaminophen*  States 
Ergocalciferol (Vitamin D2)   Vitamin or mineral product  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles, 2014.  
* These drugs were also on  the 2013 reports list of drugs commonly used by dual eligibles 
and not covered under Part D.  
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 26  Marilyn Tavenner 
APPENDIX D 
 
Inclusion of Commonly Used Drugs by Formularies in Stand-Alone Prescription 
Drug Plans* and in Medicare Advantage Prescription Drug Plans**, by Region 
 
Table D-1: PDP Formularies Inclusion of Commonly Used Drugs, by Region 
PDP  Number of   Average Rate of   Maximum 
State(s)   Minimum Rate  
Region  PDPs  Inclusion by  Formularies   Rate  
1  Maine, New Hampshire  30  95%   86%   99%  
Connecticut, Massachusetts, 
2 
Rhode Island, Vermont   31  95%   86%   99%  
3  New  York   29  95%   86%   99%  
4  New  Jersey   32  95%   86%   99%  
Delaware, the District of 
5 
Columbia, Maryland  34  96%   86%   100%  
6  Pennsylvania, West Virginia  37  95%   86%   100%  
7  Virginia  33  95%   86%   99%  
8  North Carolina   32  95%   86%   99%  
9  South Carolina   33  95%   86%   99%  
10  Georgia  32  95%   86%   99%  
11  Florida   33  95%   86%   99%  
12  Alabama, Tennessee  33  95%   86%   99%  
13  Michigan  34  95%   86%   99%  
14  Ohio   35  95%   86%   99%  
15  Indiana, Kentucky  33  95%   86%   99%  
16  Wisconsin  31  94%   86%   99%  
17  Illinois  36  94%   86%   99%  
18  Missouri  33  95%   86%   99%  
19  Arkansas  32  95%   86%   99%  
20  Mississippi   31  95%   86%   99%  
21  Louisiana  31  95%   86%   99%  
22  Texas   34  95%   86%   99%  
23  Oklahoma   34  95%   86%   99%  
24  Kansas  31  94%   86%   99%  
Iowa, Minnesota, Montana, 
25  Nebraska, North Dakota, South 
Dakota, Wyoming  32  95%   86%   99%  
26  New  Mexico  34  95%   86%   99%  
27  Colorado   32  95%   86%   99%  
28  Arizona  32  95%   86%   99%  
29  Nevada   32  95%   86%   99%  
30  Oregon, Washington  33  95%   86%   99%  
31  Idaho, Utah   35  95%   86%   99%  
32  California  34  95%   86%   99%  
33  Hawaii  27  95%   86%   99%  
34  Alaska   26  95%   86%   99%  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles, 2014. 
 
*PDPs. 
**MA-PDs.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)   Page 27  Marilyn Tavenner 
Table D-2: MA-PD Formularies Inclusion of Commonly Used Drugs, by Region  
Average Rate of  
MA-PD   Number of 
State(s)   Inclusion by   Minimum Rate   Maximum Rate  
Region***   MA-PDs  
Formularies  
1  Maine, New Hampshire  41  94%   90%   100%  
Connecticut, Massachusetts, Rhode 
2 
Island, Vermont   77  96%   90%   100%  
3  New  York   188  95%   89%   100%  
4  New  Jersey   30  96%  93%  98%  
Delaware, the District of Columbia, 
5 
Maryland   27  96%   93%   100%  
6  Pennsylvania, West Virginia  159  97%   89%   100%  
7  North Carolina, Virginia  111  96%   89%   100%  
8  Georgia, South Carolina   80  96%   89%   100%  
9  Florida   303  98%   87%   100%  
10  Alabama, Tennessee  67  97%  93%  98%  
11  Michigan  60  96%   92%   100%  
12  Ohio   88  96%   89%   100%  
13  Indiana, Kentucky  65  96%  89%  98%  
14  Illinois, Wisconsin  122  96%   89%   100%  
15  Arkansas, Missouri  82  96%  87%  99%  
16  Louisiana, Mississippi  62  97%  93%  98%  
17  Texas   132  96%  89%  99%  
18  Kansas, Oklahoma  52  96%  93%  98%  
Iowa, Minnesota, Montana, Nebraska, 
19  North Dakota, South Dakota, 
Wyoming  85  97%   88%   100%  
20  Colorado, New  Mexico  71  97%   89%   100%  
21  Arizona  68  96%   90%   100%  
22  Nevada   25  95%  90%  98%  
23  Idaho, Oregon, Utah, Washington   151  96%   89%   100%  
24  California  261  96%   89%   100%  
25  Hawaii  18  98%   96%   100%  
Source:  OIG analysis of  formulary inclusion of drugs commonly used by dual eligibles, 2014. 
***Region 26, which covers Alaska, had no MA-PDs available for 2013. 
 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:   2014 (OEI-05-14-00170)