DEPARTMENT OF HEALTH AND HUMAN SERVICES 
OFFICE OF INSPECTOR GENERAL 
WASHINGTON, DC  20201 
JUN 0 3 2013 

TO:  Marilyn Tavenner 
Administrator 

Centers for Medicare & Medicaid Services 

FROM:  Stuart Wright 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Part D Plans Generally Include Drugs Commonly 
Used by Dual Eligibles:  2013, OEI-05-13-00090 
This memorandum report fulfills the annual reporting mandate from the Patient 
Protection and Affordable Care Act of2010 (ACA) for 2013.  The ACA requires that the 
Office of Inspector General (OIG) conduct a study ofthe 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 individuals (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 third report thafOIG 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)? 
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.  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. 
1 ACA, P.L. lll-148  3313(a), 42 U.S.C.  1395w-101 note. 

2 MMA, P.L. 108-173  101, Social Security Act, 1860D-1(a), 42 U.S.C.  1395w-10l(a). 
 Page 2  Marilyn Tavenner 
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 302 unique formularies used by 
the 3,330 Part D plans operating in 2013 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 2012 to 2013, plan formularies increased the proportion of 
unique drugs subject to utilization management tools.  On average, formularies applied 
utilization management tools to 28 percent of the unique drugs we reviewed in 2013, 
compared to 24 percent of the unique drugs we reviewed in 2012. 
 
The results of our analysis for 2013 are largely unchanged from OIGs findings in both 
2011 and 2012.5, 6 
 
   
                                                 
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. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  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.7  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 2013, 
approximately 35.3 million of the 48.7 million Medicare beneficiaries were enrolled in a 
Part D plan.8, 9 
 
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.10  In 2013, plan 
sponsors offer 3,330 unique Part D plans, with many plan sponsors offering multiple 
Part D plans.11 
 
Dual Eligibles Under Medicare Part D 
Approximately 9.5 million Medicare beneficiaries are dual eligibles.12  About 7 million 
dual eligibles, referred to as full-benefit dual eligibles, receive full Medicaid benefits 
and assistance with Medicare premiums and cost-sharing.13, 14  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.15  
Additionally, dual eligibles are in worse health than the average Medicare beneficiary:  
                                                 
7 MMA, P.L. 108-173  101, Social Security Act,  1860D-1(a), 42 U.S.C.  1395w-101(a). 
8 OIG analysis of CMS data:  dual-eligible beneficiary enrollment by 2013 Part D plan.  Received 
March 4, 2013. 
9 Medicare Board of Trustees, The 2012 Annual Report of the Boards of Trustees of the Federal Hospital 
Insurance and Federal Supplementary Medical Insurance Trust Funds.  Accessed at 
http://www.treasury.gov/resource-center/economic-policy/ss-medicare/Documents/TR_2012_Medicare.pdf 
on January 17, 2013. 
10 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.  
11 OIG analysis of 2013 plan and premium information for Medicare plans offering Part D coverage.  
Accessed at http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovGenIn/PerformanceData.html November 11, 2012.  
12 OIG analysis of CMS data:  dual-eligible beneficiary enrollment by 2013 Part D plan.  Received 
March 4, 2013. 
13 Ibid.  
14 Kaiser Family Foundation, Dual Eligibles:  Medicaids Role for Low-Income Medicare Beneficiaries.  
Access at http://www.kff.org/medicaid/upload/4091-08.pdf on November 20, 2012. 
15 Kaiser Family Foundation, Medicares Role for Dual Eligible Beneficiaries.  Accessed at 
http://www.kff.org/medicare/upload/8138-02.pdf on November 20, 2012. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 4  Marilyn Tavenner 
half are in fair or poor health, more than twice the rate of others in Medicare.16  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.17   
 
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.18, 19  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.20   
 
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.21  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).22  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.23  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.24  CMS 
                                                 
16 Kaiser Family Foundation, Medicares Role for Dual Eligible Beneficiaries.  
17 MMA, P.L. 108-173  101.  
18 42 CFR  423.780(b)(2)(i).  
19 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.  
20 Patient Protection and Affordable Care Act (ACA), P.L. 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.  
21 CMS, PDBM, ch. 3,  40.1.4. 
22 Ibid.  
23 Ibid.,  30.3.2.  In general, Medicare beneficiaries can switch Part D plans only once a year during a 
defined enrollment period.  
24 Ibid.,  40.1.5.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 5  Marilyn Tavenner 
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.25  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 2013, CMS reported 
reassigning approximately 835,000 Medicare beneficiaries, including but not exclusively 
dual eligibles, because of premium increases. 
 
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.26, 27  In addition, Part D plans must 
include Part D-covered drugs in certain categories and classes.28 
 
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.29  For example, prescription vitamins, prescription mineral 
products, and nonprescription drugs are excluded from Part D prescription drug 
coverage.30   
 
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.31, 32 
 
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 
                                                 
25 CMS, PDBM, ch. 3,  40.1.5.   
26 CMS, PDBM, ch. 6,  30.2.1.   
27 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.  
28 ACA, P.L. 111-148  3307, Social Security Act,  1860D 4(b)(3)(G), 42 U.S.C.  1395w 104(b)(3)(G). 
29 MMA, P.L. 108-173  101, Social Security Act,  1860D-2(e), 42 U.S.C.  1395w-102(e).  
30 Social Security Act  1860D-2(e)(2), 1927(d)(2), 42 U.S.C.  1395w-102(e)(2), 1396r-8(d)(2). 
31 ACA, P.L. 111-148  2502, Social Security Act,  1397r-8(d). 
32 Barbiturates are covered under Part D only when used to treat epilepsy, cancer, or a chronic mental 
disorder.  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. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 6  Marilyn Tavenner 
include all drugs in specified therapeutic categories or classes.33  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.34 
 
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.35, 36, 37 
 
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.38  If their plans make negative 
determinations, beneficiaries have the right to appeal.39  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.40  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 
                                                 
33 CMS, PDBM, ch. 6,  30.2.1 and 30.2.5.   
34 Ibid.,  30.2.7.  
35 Ibid.,  30.2.2. 
36 Ibid.,  30.2.7. 
37 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.  
38 CMS, PDBM, ch. 18,  130.1 and 130.2.  
39 Ibid.,  60.1.  
40 Ibid., ch. 6,  30.4.4.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 7  Marilyn Tavenner 
dual eligibles under Medicaid prior to the implementation of Part D.  Approximately half 
of the 178 commonly used drugs were covered by all formularies.41 
 
In 2011, OIG issued the first annual mandated memorandum report examining dual 
eligibles access to drugs under Medicare Part D.42  In 2012, OIG issued the second 
annual mandated memorandum report examining dual eligibles access to drugs under 
Medicare Part D.43  In the current memorandum report, we compare the results from 
2012 and 2013. 
 
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 2013.  As part of our assessment, we 
included dual eligibles enrollment data from March 2013, the most recent enrollment 
data available from CMS at the time of our study.  We also compared the results of our 
2013 study with those of our 2012 study.44   
 
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 
2013 memorandum report are similar but not identical to the list of drugs referenced in 
the 2012 memorandum report.  Specifically, 185 of the 200 drugs (93 percent) listed in 
the 2012 memorandum report are also listed in this 2013 memorandum 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.   
 
                                                 
41 OIG, Dual Eligibles Transition:  Part D Formularies Inclusion of Commonly Used Drugs, 
OEI-05-06-00090, January 2006.  
42 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles. 
43 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2012. 
44 Ibid. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 8  Marilyn Tavenner 
We also went beyond the ACAs mandate in both the 2012 and 2013 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. 
 
Data Sources 
MCBS.  We used 2009 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 2009 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 2009, the MCBS surveyed 10,859 Medicare beneficiaries, of which 2,092 were dual 
eligibles who had used prescription drugs during the year (out of 2,299 dual-eligible 
survey respondents). 
 
First Databank National Drug Data File.  We used the December 2012 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).45 
 
Part D plan data.  In November 2012, we collected from CMS the plan and formulary 
data for Part D plans operating in 2013.  The 2013 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.  The 
2013 Part D formulary data include Part D plans formularies and utilization management 
tools.  In 2013, there are 302 unique formularies offered by 3,330 Part D plans.   
 
We also collected 2013 Part D plan enrollment data.  These data provide the number of 
dual eligibles enrolled in each Part D plan as of March 2013.   
 
Determining the Most Commonly Used Drugs 
To determine the drugs most commonly used by dual eligibles, we took the following 
steps: 
 
                                                 
45 An NDC is a three-part universal identifier that specifies the drug manufacturers name, the drug form 
and strength, and the package size. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 9  Marilyn Tavenner 
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 154,267 drug events listed for 
2,090 dual eligibles in the MCBS that did not reside in territories.46 
 
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 153,789 drug events associated with 864 drugs.  There were 478 drug events 
in the MCBS that could not be matched with an Ingredient List Identifier in First 
DataBanks National Drug Data File.   
 
3.  Ranked all 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, 2 fell into drug categories excluded 
under Part D, 1 is no longer prescribed in the form taken by beneficiaries 
surveyed in the 2009 MCBS, and 1 is no longer available in the United States.  
One additional drug is eligible for Part D prescription drug coverage.  However, 
we did not include it in our analysis because we could not confidently project the 
use of this drug to the entire dual-eligible beneficiary population.  For details on 
the four drugs excluded under Part D, see Appendix C. 
 
Formulary Analysis 
We analyzed the 302 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 
                                                 
46 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 2009.  For example, one MCBS survey respondent reported 
taking atenolol 8 times in 2009.  We counted this beneficiary/drug combination as 8 drug events.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 10  Marilyn Tavenner 
302 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. 
 
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 2009 account for 87 percent of all prescriptions dispensed 
to the dual-eligible respondents in the 2009 MCBS.    
 
Because the lists of commonly used drugs in the 2012 and 2013 memorandum reports are 
not identical, changes in rates of inclusion by formularies and in application of utilization 
management tools between 2012 and 2013 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; 93 percent of the drugs reviewed in the 2012 memorandum 
report are the same as those reviewed in this 2013 memorandum report. 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 11  Marilyn Tavenner 
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 85 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 302 unique formularies used by Part D plans in 2013, 
19 formularies include 100 percent of the commonly used drugs.  At the other end of the 
inclusion range, one formulary includes 85 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 
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 2013 
is nearly identical to that of 2012.  The average rate of inclusion96 percentwas 
unchanged between 2012 and 2013.  The ranges of inclusion in 2012 and 2013 are almost 
the samein 2012, the rates of inclusion ranged from 83 to 100 percent of the drugs 
commonly used by dual eligibles, and in 2013, they ranged from 85 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 87 to 
100 percent, and MA-PD formularies rates ranged from 85 to 100 percent.  Twenty-one 
formularies7 percent of the 302 unique formularies used by Part D plans in 2013are 
offered by both PDPs and MA-PDs. 
 
Regionally, all dual eligibles have the choice of a Part D plan that includes at least 
99 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 99 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 
87 percent to 100 percent.  Approximately 73 percent of dual eligibles are enrolled in 
Part D plans with premiums below the regional benchmark. 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 12  Marilyn Tavenner 
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. 
 
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  175,000  2% 
95% to 99% of commonly used drugs  3,329,000  35% 
90% to 94% of commonly used drugs  5,821,000  62% 
85% to 89% of commonly used drugs  126,000  1% 
     Total  9,451,000  100% 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles and dual eligibles 
enrollment, 2013. 
*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 2012 and 2013 
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 51 percent to 100 percent.  In other words, one drug commonly 
used by dual eligibles is included in as few as 51 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 D 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 302 Formularies  Used Drugs Included in 
Formularies 
64% 
100% 
(125 drugs) 
24% 
85% to 99% 
(47 drugs) 
4% 
75% to 84% 
(7 drugs) 
8% 
51% to 74% 
(16 drugs) 
100% 
    Total 
(195 drugs) 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2013. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 13  Marilyn Tavenner 
The rates of formulary inclusion of the drugs commonly used by dual eligibles in 2013 
are similar to those in 2012.  The percentage of commonly used drugs included in all 
formularies increased slightly between 2012 and 2013, from 61 percent to 64 percent. 
 
Part D plan formularies include certain drugs less frequently than others.  Of the 
commonly used drugs, 8 percent (16 drugs) are included by less than 75 percent of Part D 
plan formularies.  Table 3 provides the percentage of formularies covering each of these 
16 drugs.   
 
The drugs that make up this group include both brand and generic drugs, and are used to 
treat a variety of primary indications.  Seven of the sixteen drugs are brand-name drugs, 
which are typically more costly than generic drugs.  In terms of primary indications, 4 of 
the 16 drugs are used to treat high blood pressure, 3 of the 16 drugs are muscle relaxants, 
and the remaining treat a variety of conditions including high cholesterol, asthma, 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 
Valsartan/hydrochlorothiazide  Hypertension (high blood pressure)  74% 
Olmesartan/hydrochlorothiazide*  Hypertension (high blood pressure)  73% 
Olmesartan medoxomil*  Hypertension (high blood pressure)  73% 
Valsartan  Hypertension (high blood pressure)  73% 
Cyclobenzaprine HCL  Muscle relaxant  70% 
Methocarbamol  Muscle relaxant  70% 
Diphenoxylate HCL/atropine  Antidiarrheal  66% 
Ezetimibe/simvastatin*  Hyperlipidemia (high cholesterol)  62% 
Hyperlipidemia (high cholesterol),  
Fenofibrate nanocrystallized  62% 
hypertriglyceridemia (high triglycerides) 
Temazepam  Insomnia  62% 
Dyspepsia, peptic ulcer disease, gastroesophageal reflux 
Esomeprazole magnesium*  60% 
disease, Zollinger-Ellison syndrome 
Alprazolam  Anxiety  59% 
Eszopiclone*  Insomnia  59% 
Rosiglitazone maleate*  Insulin sensitizer  56% 
Carisoprodol*  Muscle relaxant  52% 
Levalbuterol tartrate*  Asthma, chronic obstructive pulmonary disease  51% 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2013. 
* These drugs also had low formulary inclusion rates in 2012. 
 
Although Part D formularies frequently omit these 16 drugs, they all cover other drugs in 
the same therapeutic classes.  For 15 of these 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.  Finally, 100 percent of formularies cover drugs in the same 
therapeutic class as the remaining low-inclusion drug, diphenoxylate HCl/atropine.47  
 
                                                 
47 The drugs in the same therapeutic class as diphenoxylate HCl/atropine are not always on the list of 
195 commonly used drugs. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 14  Marilyn Tavenner 
The number of drugs included by less than 75 percent of formularies increased from 11 in 
2012 to 16 in 2013.  There are eight drugs with low inclusion rates in 2013 that were also 
on the list of commonly used drugs with low inclusion rates in our 2012 report; these 
drugs are noted in Table 3.  An additional 5 of the 16 low-inclusion drugs in 2013 were 
on the list of commonly used drugs in our 2012 report, and the final 3 of the 
16 low-inclusion drugs in our 2013 report were either not covered by Part D in 2012 or 
were not on the list of commonly used drugs in the 2012 report.   
 
There are many potential reasons why a commonly used drug might be included by less 
than 75 percent of formularies: 
 
  Three of these drugscyclobenzaprine HCl, diphenoxylate HCl/atropine, and 
methocarbamolare on CMSs list of high-risk Part D medications, which may 
explain the low inclusion rates for these drugs.48  Part D formularies have 
increasingly excluded these drugs since they were placed on the high-risk 
medication list in 2011. 
  Another two drugsvalsartan and valsartan/hydrochlorothiazidereceived 
first-time generic drug approval from the Food and Drug Administration on 
September 21, 2012.  Thus, Part D formularies may now cover different generic 
forms of these drugs. 
  The decrease in formulary coverage of fenofibrate nanocrystallized may be driven 
by the fact that the nanocrystallized form of fenofibrate is more expensive than 
other forms of fenofibrate. 
  Two drugstemazepam and alprazolamare benzodiazepines, which were 
excluded from Part D coverage until 2013.  These two drugs were also on the list 
of commonly used drugs in our 2012 report.  The low inclusion rates for these two 
drugs may be explained by CMSs recent 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.49  Finally, dual eligibles may switch to Part D 
                                                 
48 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/HEDIS2012FinalNDCList
s.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. 
49 CMS, PDBM, ch. 18,  30.2.2. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 15  Marilyn Tavenner 
plans that include their drugs, with the new coverage becoming effective the following 
month.50 
 
Plan Formularies Increased the Percentage of Commonly Used Drugs Subject to 
Utilization Management Tools Between 2012 and 2013 
For the unique drugs that compose the list of commonly used drugs, Part D plan 
formularies increased the percentage subject to utilization management tools, from an 
average of 24 percent in 2012 to an average of 28 percent in 2013.  Among the 
formularies, those for plans with premiums below the regional benchmark had a slightly 
larger increase in this percentage between 2012 and 2013, going from an average of 
22 percent in 2012 to an average of 27 percent in 2013.  See Table 4 for a breakdown of 
the percentage of unique drugs to which Part D plan formularies apply utilization 
management tools in 2012 and 2013. 
 
Table 4:  Part D Plan Formularies Application of Utilization Management Tools to 
Commonly Used Drugs, 2012 to 2013 
Percentage of Unique Drugs  Number of  Percentage of  Number of 
Percentage of 
to Which Utilization  2012 Part D  2012 Part D  2013 Part D 
2013 Part D Plan 
Management Tools Are  Plan  Plan  Plan 
Formularies 
Applied  Formularies  Formularies  Formularies 
40% to 55%  31  11%  41  13% 
30% to 39%  59  22%  116  38% 
20% to 29%  92  34%  74  25% 
10% to 19%  54  20%  34  11% 
Less than 10%  36  13%  37  12% 
     Totals  272  100%  302  100%* 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2013. 
* Percentages do not add to 100 percent because of rounding. 
 
This increase in Part D plan formularies application of utilization management tools 
results partially from an increase in the rate at which formularies apply quantity limits to 
the unique drugs that make up commonly used drugs.  In 2013, formularies applied such 
quantity limits to an average of 24 percent of unique drugs, up from 21 percent in 2012.  
There is also a slight increase in the rate at which formularies apply prior authorization to 
the unique drugs that make up commonly used drugs.  In 2013, formularies applied prior 
authorization to an average of 5 percent of unique drugs, up from 3 percent in 2012.  
Formularies applied step therapy at virtually the same rate in 2013 as in 2012, that is, for 
an average of 3 percent of unique drugs.  
 
Although there has been an overall increase in Part D plan formularies use of utilization 
management tools, wide variation remains in the rate at which plan formularies apply 
these tools.  In 2013, some formularies applied utilization management tools to none of 
the unique drugs, whereas at the other end of the range, some applied the tools to 
55 percent of the unique drugs.  More specifically, formularies apply quantity limits to 
between 0 and 44 percent of unique drugs, prior authorization to between 0 and 
29 percent, and step therapy to between 0 and 20 percent.  
 
                                                 
50 CMS, PDBM, ch. 3,  30.3.2. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 16  Marilyn Tavenner 
Looking at enrollment across plans provides a slightly different picture than looking only 
at plans themselves.  On average, plan formularies in 2013 apply utilization management 
tools to 28 percent of unique drugs.  However, dual eligibles tend to be enrolled in plans 
with formularies that apply these tools at a slightly higher rate; in 2013, the median plan 
weighted by dual-eligible enrollment applies such tools to 35 percent of unique drugs.  
This is an increase over 2012, when the median plan weighted by dual-eligible 
enrollment applied utilization management tools to 26 percent of unique drugs.  
Similarly, the median plan weighted by overall Medicare enrollment applies these tools 
to 32 percent of unique drugs in 2013, up from 26 percent in 2012.   
 
Both dual eligibles and Medicare beneficiaries overall tend to be enrolled in plans with 
formularies that apply utilization management tools to between 30 and 55 percent of 
unique drugs.  In 2013, 62 percent of dual eligibles and 54 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 plans formularies application of utilization management tools.   
 
Table 5:  Beneficiary Enrollment in Part D Plans by Application of Utilization 
Management Tools to Commonly Used Drugs, 2012 to 2013 
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, 2012  Enrolled, 2013 
Enrolled, 2012  Enrolled, 2013 
40% to 55%  22%  21%  18%  20% 
30% to 39%  22%  23%  44%  34% 
20% to 29%  44%  42%  16%  12% 
10% to 19%  2%  4%  6%  5% 
Less than 10%  9%  10%  17%  29% 
     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, 2013. 
*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.  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.51 
 
CONCLUSION 
 
When establishing formularies and applying utilization management tools, Part D plans 
need to balance Medicare beneficiaries needs for adequate prescription drug coverage 
                                                 
51 CMS, Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D.  
September 6, 2012.  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:  2013 (OEI-05-13-00090)  Page 17  Marilyn Tavenner 
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 16 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 85 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. 
 
Inclusion rates for the 195 drugs commonly used by dual eligibles are largely unchanged 
compared with those from OIGs 2012 memorandum report.  Part D plan formularies 
include roughly the same percentage of these commonly used drugs in 2013 as they did 
in 2012.  Enrollment in plans that cover at least 90 percent of unique drugs stayed 
consistent, with 99 percent of dual eligibles enrolled in such plans.     
 
Although dual eligibles, like all Medicare beneficiaries, are largely enrolled in plans that 
apply utilization management tools to a higher than average percentage of unique drugs, 
this increase is largely a result of an increase in plans use of quantity limits and prior 
authorization requirements.  Plan formularies still vary widely in the rates at which they 
apply utilization management tools to unique drugs. 
 
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 memorandum report, 
please provide them within 60 days.  Please refer to report number OEI-05-13-00090 in 
all correspondence. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  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:  2013 (OEI-05-13-00090)  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  
Number of  Percentage of 
Sample  Projected  95-Percent Confidence 
Generic Name  Formularies  Formularies 
Size*  Drugs*  Interval* 
Including  Including 
Furosemide  3,888  14,488,713  12,777,105 - 16,200,322  302  100% 
Simvastatin  3,459  13,936,580  12,555,541 - 15,317,618  301  100% 
Hydrocodone 
3,846  13,670,886  11,729,808 - 15,611,964  302  100% 
bit/acetaminophen 
Lisinopril  3,483  13,610,671  12,242,398 - 14,978,945  302  100% 
Levothyroxine sodium  3,371  12,400,820  10,971,169 - 13,830,471  302  100% 
Omeprazole  3,093  11,964,177  10,423,382 - 13,504,972  302  100% 
Potassium chloride  2,938  10,471,432  9,141,466 - 11,801,399  302  100% 
Amlodipine besylate  2,595  10,238,851  8,725,274 - 11,752,429  302  100% 
Metoprolol tartrate  2,393  9,382,516  8,286,197 - 10,478,834  302  100% 
Metformin HCl  2,216  8,789,649  7,682,215 - 9,897,084  302  100% 
Warfarin sodium  2,317  8,522,219  7,189,261 - 9,855,177  302  100% 
Atorvastatin calcium  2,039  7,644,118  6,588,676 - 8,699,560  301  100% 
Hydrochlorothiazide  1,717  7,268,389  6,083,158 - 8,453,620  302  100% 
Clopidogrel bisulfate  1,828  6,899,724  5,924,280 - 7,875,167  302  100% 
Atenolol  1,545  6,801,703  5,648,924 - 7,954,482  302  100% 
Esomeprazole magnesium  1,435  5,973,325  4,771,051 - 7,175,599  180  60% 
Gabapentin  1,630  5,843,387  4,861,226 - 6,825,548  302  100% 
Albuterol sulfate  1,439  5,219,654  4,432,757 - 6,006,551  302  100% 
Alendronate sodium  1,032  5,033,461  4,081,433 - 5,985,489  302  100% 
Citalopram hydrobromide  1,273  4,853,755  3,828,500 - 5,879,010  302  100% 
Zolpidem tartrate  1,378  4,757,715  3,812,965 - 5,702,464  302  100% 
Quetiapine fumarate  1,569  4,428,322  3,491,367 - 5,365,277  302  100% 
Metoprolol succinate  1,088  4,326,590  3,575,455 - 5,077,725  299  99% 
Ranitidine HCl  1,282  4,241,484  3,386,165 - 5,096,803  302  100% 
Valsartan  1,041  4,193,143  3,342,936 - 5,043,350  221  73% 
Glipizide  977  4,040,914  3,269,449 - 4,812,379  302  100% 
Fluticasone/salmeterol  1,067  4,035,986  3,198,380 - 4,873,592  289  96% 
Insulin glargine, human 
952  4,017,723  3,061,997 - 4,973,449  295  98% 
recombinant analog 
Sertraline HCl  1,238  3,974,084  3,223,944 - 4,724,224  302  100% 
Montelukast sodium  977  3,810,128  2,954,872 - 4,665,384  270  89% 
Lovastatin  797  3,806,610  2,995,644 - 4,617,575  291  96% 
Divalproex sodium  1,349  3,704,559  2,860,276 - 4,548,842  302  100% 
Oxycodone 
1,016  3,702,234  2,918,165 - 4,486,303  302  100% 
HCl/acetaminophen 
Carvedilol  907  3,636,584  2,960,891 - 4,312,277  302  100% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 20  Marilyn Tavenner 
Table B-1:  200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of  Percentage of 
Sample  Projected  95-Percent Confidence 
Generic Name  Formularies  Formularies 
Size*  Drugs*  Interval* 
Including  Including 
Donepezil HCl  1,121  3,620,751  2,858,713 - 4,382,789  302  100% 
Diltiazem HCl  841  3,536,775  2,618,064 - 4,455,485  302  100% 
Trazodone HCl  1,002  3,503,016  2,777,254 - 4,228,777  302  100% 
Escitalopram oxalate  1,059  3,410,096  2,716,579 - 4,103,614  287  95% 
Isosorbide mononitrate  933  3,409,185  2,681,156 - 4,137,215  302  100% 
Pantoprazole sodium  891  3,284,951  2,531,046 - 4,038,855  297  98% 
Risperidone  1,139  3,199,726  2,641,085 - 3,758,367  302  100% 
Cyclobenzaprine HCl  862  3,161,124  2,448,504 - 3,873,745  212  70% 
Tramadol HCl  925  3,106,442  2,396,534 - 3,816,350  302  100% 
Rosuvastatin calcium  721  3,086,871  2,335,607 - 3,838,136  242  80% 
Alprazolam  837  3,033,650  2,350,951 - 3,716,349  177  59% 
Lansoprazole  824  3,002,134  2,342,667 - 3,661,601  262  87% 
Pioglitazone HCl  795  2,986,021  2,270,495 - 3,701,547  301  100% 
Ibuprofen  811  2,936,951  2,285,745 - 3,588,158  302  100% 
Enalapril maleate  828  2,886,367  2,331,576 - 3,441,158  302  100% 
Prednisone  838  2,882,757  2,383,115 - 3,382,399  302  100% 
Fluticasone propionate  776  2,859,018  2,324,821 - 3,393,216  302  100% 
Digoxin  733  2,857,313  2,231,221 - 3,483,406  302  100% 
Clonidine HCl  734  2,800,964  2,107,146 - 3,494,782  302  100% 
Propoxyphene 
814  2,694,310  2,078,897 - 3,309,723  Excluded   Excluded 
nap/acetaminophen 
Allopurinol  710  2,568,090  1,982,006 - 3,154,174  302  100% 
Lisinopril/hydrochlorothiazide  657  2,558,335  1,908,086 - 3,208,583  301  100% 
Paroxetine HCl  746  2,494,774  1,909,116 - 3,080,433  302  100% 
Tiotropium bromide  573  2,456,029  1,935,499 - 2,976,559  302  100% 
Mirtazapine  777  2,444,280  1,811,924 - 3,076,636  302  100% 
Naproxen  689  2,410,096  1,864,556 - 2,955,635  302  100% 
Pravastatin sodium  578  2,408,314  1,685,343 - 3,131,284  302  100% 
Tamsulosin HCl  595  2,330,145  1,722,438 - 2,937,853  302  100% 
Valsartan/hydrochlorothiazide  550  2,298,873  1,654,679 - 2,943,067  224  74% 
Clonazepam  733  2,262,762  1,722,387 - 2,803,137  302  100% 
Fluoxetine HCl  652  2,259,917  1,776,469 - 2,743,365  302  100% 
Glimepiride  522  2,242,751  1,588,355 - 2,897,146  302  100% 
Azithromycin  654  2,184,924  1,908,989 - 2,460,859  302  100% 
Meloxicam  516  2,155,762  1,647,492 - 2,664,031  300  99% 
Aripiprazole  709  2,149,920  1,452,541 - 2,847,298  302  100% 
Spironolactone  488  2,087,297  1,511,754 - 2,662,839  302  100% 
Pregabalin  616  2,055,748  1,458,317 - 2,653,179  302  100% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 21  Marilyn Tavenner 
Table B-1:  200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of  Percentage of 
Sample  Projected  95-Percent Confidence 
Generic Name  Formularies  Formularies 
Size*  Drugs*  Interval* 
Including  Including 
Ezetimibe  541  2,021,031  1,478,673 - 2,563,389  302  100% 
Nitroglycerin  583  2,012,596  1,622,179 - 2,403,014  302  100% 
Sulfamethoxazole/ 
619  2,011,424  1,619,682 - 2,403,167  302  100% 
trimethoprim 
Famotidine  542  1,996,592  1,581,286 - 2,411,898  299  99% 
Morphine sulfate  619  1,994,878  1,328,559 - 2,661,197  302  100% 
Duloxetine HCl  546  1,992,643  1,293,371 - 2,691,915  302  100% 
Ipratropium/albuterol sulfate  470  1,970,144  1,460,358 - 2,479,930  298  99% 
Memantine HCl  631  1,961,892  1,456,342 - 2,467,442  302  100% 
Glyburide  495  1,922,621  1,384,185 - 2,461,058  300  99% 
Oxybutynin chloride  550  1,909,731  1,492,216 - 2,327,245  302  100% 
Fexofenadine HCl  585  1,902,635  1,446,691 - 2,358,578   Excluded  Excluded 
Olanzapine  693  1,896,640  1,319,011 - 2,474,270  302  100% 
Amitriptyline HCl  564  1,885,388  1,372,287 - 2,398,489  302  100% 
Ciprofloxacin HCl  568  1,865,328  1,639,946 - 2,090,710  302  100% 
Losartan potassium  404  1,856,087  1,306,715 - 2,405,458  302  100% 
Fenofibrate nanocrystallized  488  1,824,334  1,406,247 - 2,242,421  186  62% 
Venlafaxine HCl  643  1,823,318  1,272,552 - 2,374,085  302  100% 
Nifedipine  426  1,820,394  1,280,987 - 2,359,801  300  99% 
Tolterodine tartrate  531  1,782,318  1,375,463 - 2,189,173  239  79% 
Triamterene/ 
446  1,773,800  1,164,934 - 2,382,666  302  100% 
hydrochlorothiazide 
Levofloxacin  500  1,766,041  1,363,889 - 2,168,194  301  100% 
Polyethylene glycol 3350  519  1,721,331  1,221,512 - 2,221,149  296  98% 
Buspirone HCl  460  1,702,854  1,221,714 - 2,183,993  302  100% 
Promethazine HCl  550  1,686,330  1,284,972 - 2,087,688  268  89% 
Sitagliptin phosphate  360  1,667,857  1,148,378 - 2,187,336  295  98% 
Bupropion HCl  472  1,666,187  1,186,998 - 2,145,377  302  100% 
Human insulin neutral 
protamine hagedorn/regular  463  1,653,338  1,196,825 - 2,109,851  302  100% 
human insulin 
Celecoxib  435  1,621,197  1,186,593 - 2,055,800  282  93% 
Metoclopramide HCl  443  1,617,265  1,174,504 - 2,060,026  302  100% 
Phenytoin sodium extended  547  1,613,514  1,163,676 - 2,063,352  302  100% 
Carbamazepine  576  1,580,353  1,013,148 - 2,147,559  302  100% 
Ezetimibe/simvastatin  341  1,541,184  977,289 - 2,105,078  186  62% 
Risedronate sodium  396  1,540,508  1,101,037 - 1,979,980  228  75% 
Clozapine  400  1,509,207  714,436 - 2,303,978  302  100% 
Acetaminophen with codeine  359  1,484,631  1,013,126 - 1,956,136  302  100% 
Meclizine HCl  415  1,463,788  1,091,434 - 1,836,142  297  98% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 22  Marilyn Tavenner 
Table B-1:  200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of  Percentage of 
Sample  Projected  95-Percent Confidence 
Generic Name  Formularies  Formularies 
Size*  Drugs*  Interval* 
Including  Including 
Mometasone furoate  391  1,458,895  1,068,476 - 1,849,315  300  99% 
Insulin regular, human  385  1,457,603  1,030,919 - 1,884,288  302  100% 
Glyburide/metformin HCl  306  1,455,464  938,542 - 1,972,386  298  99% 
Carisoprodol  502  1,442,655  995,945 - 1,889,365  156  52% 
Oxycodone HCl  498  1,431,700  989,649 - 1,873,751  301  100% 
Baclofen  468  1,406,908  987,451 - 1,826,366  302  100% 
Fentanyl  421  1,401,086  952,557 - 1,849,616  302  100% 
Cephalexin  440  1,396,294  1,165,811 - 1,626,778  302  100% 
Insulin aspart  368  1,382,200  927,459 - 1,836,940  285  94% 
Benztropine mesylate  524  1,378,431  955,176 - 1,801,686  302  100% 
Diazepam  345  1,350,444  891,523 - 1,809,365  302  100% 
Doxazosin mesylate  283  1,315,296  734,304 - 1,896,287  302  100% 
Hydroxyzine HCl  327  1,309,855  797,158 - 1,822,551  257  85% 
Ziprasidone HCl  473  1,283,163  838,260 - 1,728,066  302  100% 
Benazepril HCl  307  1,275,932  720,547 - 1,831,316  301  100% 
Triamcinolone acetonide  361  1,260,803  1,039,762 - 1,481,843  302  100% 
Lidocaine  347  1,258,091  856,044 - 1,660,138  302  100% 
Verapamil HCl  311  1,238,088  863,750 - 1,612,426  302  100% 
Latanoprost  302  1,227,112  819,015 - 1,635,210  302  100% 
Amoxicillin  405  1,226,521  1,044,796 - 1,408,246  302  100% 
Carbidopa/levodopa  361  1,215,696  832,796 - 1,598,596  302  100% 
Hydralazine HCl  333  1,201,268  836,146 - 1,566,389  302  100% 
Amlodipine 
298  1,201,014  803,666 - 1,598,361  293  97% 
besylate/benazepril 
Torsemide  230  1,173,205  492,351 - 1,854,059  299  99% 
Nystatin  326  1,170,065  857,188 - 1,482,941  302  100% 
Lamotrigine  391  1,159,822  771,629 - 1,548,014  302  100% 
Ramipril  289  1,142,525  665,969 - 1,619,081  296  98% 
Gemfibrozil  313  1,132,380  777,795 - 1,486,966  302  100% 
Ropinirole HCl  280  1,125,551  686,763 - 1,564,339  302  100% 
Terazosin HCl  255  1,116,887  681,820 - 1,551,954  302  100% 
Methocarbamol  307  1,110,468  663,592 - 1,557,343  210  70% 
Isosorbide dinitrate  261  1,110,025  469,055 - 1,750,994  302  100% 
Lorazepam  374  1,105,423  829,210 - 1,381,635  234  77% 
Estrogens, conjugated  261  1,083,989  629,284 - 1,538,695  300  99% 
Folic acid  268  1,074,524  785,018 - 1,364,029   Excluded  Excluded 
Lactulose  335  1,073,756  696,324 - 1,451,188  302  100% 
Lithium carbonate  319  1,056,530  544,694 - 1,568,365  302  100% 
Levetiracetam  372  1,052,523  722,361 - 1,382,685  302  100% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 23  Marilyn Tavenner 
Table B-1:  200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of  Percentage of 
Sample  Projected  95-Percent Confidence 
Generic Name  Formularies  Formularies 
Size*  Drugs*  Interval* 
Including  Including 
Omega-3 acid ethyl esters  270  1,034,241  593,395 - 1,475,087  299  99% 
Doxycycline hyclate  337  1,033,606  751,965 - 1,315,246  302  100% 
Methadone HCl  271  1,008,892  466,535 - 1,551,248  301  100% 
Topiramate  397  1,000,887  583,646 - 1,418,128  302  100% 
Neutral protamine hagedorn, 
217  988,784  639,247 - 1,338,320  302  100% 
human insulin isophane 
Ipratropium bromide  272  980,422  653,215 - 1,307,629  302  100% 
Brimonidine tartrate  245  954,347  657,682 - 1,251,013  302  100% 
Propranolol HCl  285  948,052  571,036 - 1,325,068  302  100% 
Temazepam  250  946,044  610,453 - 1,281,635  187  62% 
Dicyclomine HCl  276  943,314  607,856 - 1,278,771  253  84% 
Finasteride  249  910,448  615,843 - 1,205,053  302  100% 
Timolol maleate  245  861,731  565,750 - 1,157,712  302  100% 
Fluconazole  242  860,524  466,493 - 1,254,555  302  100% 
Albuterol  241  853,696  489,990 - 1,217,403   Excluded  Excluded 
Pramipexole dihydrochloride  121  Excluded  Excluded  Excluded  Excluded 
Labetalol HCl  183  841,200  174,911 - 1,507,488  302  100% 
Olmesartan medoxomil  181  829,968  349,332 - 1,310,605  220  73% 
Insulin lispro  204  819,910  516,648 - 1,123,172  241  80% 
Nabumetone  206  814,711  481,191 - 1,148,232  298  99% 
Quinapril HCl  150  813,879  351,190 - 1,276,569  298  99% 
Raloxifene HCl  202  812,930  478,798 - 1,147,062  302  100% 
Tizanidine HCl  280  812,885  545,990 - 1,079,780  301  100% 
Diclofenac sodium  224  809,011  579,543 - 1,038,480  302  100% 
Amoxicillin/potassium 
258  807,971  635,629 - 980,312  302  100% 
clavulanate 
Methylprednisolone  214  786,567  513,393 - 1,059,741  302  100% 
Oxcarbazepine  213  779,355  266,529 - 1,292,181  302  100% 
Nitrofurantoin monohydrate/ 
226  772,565  585,184 - 959,945  292  97% 
macrocrystals 
Eszopiclone  229  760,246  400,596 - 1,119,897  177  59% 
Solifenacin succinate  210  751,939  442,997 - 1,060,881  249  82% 
Levalbuterol tartrate  176  732,957  357,407 - 1,108,506  154  51% 
Metolazone  203  726,108  417,302 - 1,034,915  300  99% 
Cilostazol  148  719,471  324,291 - 1,114,651  302  100% 
Rosiglitazone maleate  206  715,668  407,155 - 1,024,182  170  56% 
Azelastine HCl  129  699,431  282,352 - 1,116,510  302  100% 
Clotrimazole/ 
187  692,186  481,069 - 903,302  267  88% 
betamethasone dip 
Dutasteride  127  684,615  404,255 - 964,975  279  92% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 24  Marilyn Tavenner 
Table B-1:  200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of  Percentage of 
Sample  Projected  95-Percent Confidence 
Generic Name  Formularies  Formularies 
Size*  Drugs*  Interval* 
Including  Including 
Sucralfate  213  681,391  408,441 - 954,342  302  100% 
Diphenoxylate HCl/atropine  169  668,573  284,464 - 1,052,682  200  66% 
Megestrol acetate  199  639,426  450,033 - 828,820  302  100% 
Clobetasol propionate  146  636,503  322,115 - 950,891  302  100% 
Metronidazole  185  625,506  460,269 - 790,743  302  100% 
Amiodarone HCl  146  620,999  327,394 - 914,604  302  100% 
Colchicine  200  607,224  314,858 - 899,591  302  100% 
Sotalol HCl  152  596,852  245,850 - 947,853  302  100% 
Aspirin/dipyridamole  165  594,285  347,901 - 840,668  302  100% 
Losartan/hydrochlorothiazide  166  593,970  243,138 - 944,802  301  100% 
Dorzolamide HCl/timolol 
151  592,202  305,698 - 878,706  302  100% 
maleate 
Ketoconazole  162  579,942  365,474 - 794,411  302  100% 
Nitrofurantoin macrocrystal  177  577,871  349,562 - 806,181  294  97% 
Hydroxychloroquine sulfate  155  577,507  251,571 - 903,442  302  100% 
Calcium acetate  180  573,946  313,698 - 834,193  298  99% 
Repaglinide  142  569,993  308,053 - 831,933  267  88% 
Moxifloxacin HCl  137  568,317  364,110 - 772,525  287  95% 
Hydrocortisone  154  554,472  305,094 - 803,851  302  100% 
Olmesartan/ 
113  552,362  259,710 - 845,014  220  73% 
hydrochlorothiazide 
Source:  Office of Inspector General analysis of drugs commonly used by dual eligibles, 2013. 
*Sample is from the 2009 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:  2013 (OEI-05-13-00090)  Page 25  Marilyn Tavenner 
APPENDIX C 
 
Four 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 
No longer available in the United 
Propoxyphene nap/acetaminophen* 
States 
Source:  Office of Inspector General analysis of formulary inclusion of drugs commonly used 
by dual eligibles, 2013. 
* These drugs were also on the 2012 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:  2013 (OEI-05-13-00090)  Page 26  Marilyn Tavenner 
APPENDIX D 
 
Formulary Inclusion of Stand-Alone Prescription Drug Plans* and Medicare 
Advantage Prescription Drug Plans** by Region 
 
Table D-1:  PDP Formulary Inclusion 
PDP  Number of  Average Formulary  Maximum 
State(s)  Minimum Rate 
Region  PDPs  Inclusions Rate  Rate 
1  Maine, New Hampshire  28  95%  87%  99% 
Connecticut, Massachusetts, 
2  30  95%  87%  99% 
Rhode Island, Vermont 
3  New York  28  95%  87%  99% 
4  New Jersey  29  94%  87%  99% 
Delaware, the District of 
5  29  95%  87%  99% 
Columbia, Maryland 
6  Pennsylvania, West Virginia  38  95%  87%  100% 
7  Virginia  31  94%  87%  99% 
8  North Carolina  30  95%  87%  99% 
9  South Carolina  31  94%  87%  99% 
10  Georgia  30  95%  87%  99% 
11  Florida  34  94%  87%  99% 
12  Alabama, Tennessee  33  95%  87%  99% 
13  Michigan  33  95%  87%  99% 
14  Ohio  33  95%  87%  99% 
15  Indiana, Kentucky  31  95%  87%  99% 
16  Wisconsin  30  95%  87%  99% 
17  Illinois  32  95%  87%  99% 
18  Missouri  31  94%  87%  99% 
19  Arkansas  30  94%  87%  99% 
20  Mississippi  29  94%  87%  99% 
21  Louisiana  30  94%  87%  99% 
22  Texas  32  95%  87%  99% 
23  Oklahoma  30  94%  87%  99% 
24  Kansas  30  94%  87%  99% 
Iowa, Minnesota, Montana, 
25  Nebraska, North Dakota, South  32  95%  87%  99% 
Dakota, Wyoming 
26  New Mexico  30  95%  87%  99% 
27  Colorado  29  95%  87%  99% 
28  Arizona  29  95%  87%  99% 
29  Nevada  29  95%  87%  99% 
30  Oregon, Washington  30  94%  87%  99% 
31  Idaho, Utah  32  94%  87%  99% 
32  California  32  94%  87%  99% 
33  Hawaii  23  94%  87%  99% 
34  Alaska  23  95%  87%  99% 
Source:  Office of Inspector General analysis of formulary inclusion of drugs commonly used by dual eligibles, 2013. 
 
*PDP. 
**MA-PD. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)  Page 27  Marilyn Tavenner 
Table D-2:  MA-PD Formulary Inclusion by Region 
MA-PD  Number of  Average Formulary 
State(s)  Minimum Rate  Maximum Rate 
Region***   MA-PDs  Inclusion Rate 
1  Maine, New Hampshire  36  96%  87%  99% 
Connecticut, Massachusetts, Rhode 
2  72  96%  87%  99% 
Island, Vermont 
3  New York  189  96%  90%  99% 
4  New Jersey  36  95%  91%  99% 
Delaware, the District of Columbia, 
5  28  96%  93%  100% 
Maryland 
6  Pennsylvania, West Virginia  157  97%  90%  100% 
7  North Carolina, Virginia  140  97%  87%  100% 
8  Georgia, South Carolina  125  96%  87%  100% 
9  Florida  302  97%  85%  100% 
10  Alabama, Tennessee  77  96%  93%  99% 
11  Michigan  61  97%  93%  100% 
12  Ohio  80  96%  87%  100% 
13  Indiana, Kentucky  88  96%  87%  100% 
14  Illinois, Wisconsin  142  97%  87%  100% 
15  Arkansas, Missouri  123  96%  87%  99% 
16  Louisiana, Mississippi  80  96%  93%  99% 
17  Texas  149  96%  90%  99% 
18  Kansas, Oklahoma  65  97%  90%  99% 
Iowa, Minnesota, Montana, Nebraska, 
19  North Dakota, South Dakota,  122  97%  88%  100% 
Wyoming 
20  Colorado, New Mexico  74  97%  87%  100% 
21  Arizona  75  95%  89%  99% 
22  Nevada  38  95%  87%  100% 
23  Idaho, Oregon, Utah, Washington  160  96%  90%  100% 
24  California  266  96%  87%  100% 
25  Hawaii  20  97%  94%  100% 
Source:  Office of Inspector General analysis of formulary inclusion of drugs commonly used by dual eligibles, 2013. 
***Region 26, which covers Alaska, has no MA-PDs available for 2013. 
 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013 (OEI-05-13-00090)