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/S/ Page 2  Andrew M. Slavitt 
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 are allowed 
to 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 report, we determined whether the 374 unique formularies used by the 
3,116 Part D plans operating in 2016 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, 68 percent of 
the commonly used drugs are included by all Part D plan formularies.   
 
We also found that from 2015 to 2016, the proportion of unique drugs subject to 
utilization management tools remained relatively the same.  On average, formularies 
applied utilization management tools to 28 percent of the unique drugs we reviewed in 
2016, compared to 29 percent of those we reviewed in 2015. 
 
The results of our analysis for 2016 are largely unchanged from our findings in 2011, 
2012, 2013, 2014, and 2015.5, 6, 7, 8, 9 
 
 
   
                                                 
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).   
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 drug therapy that is the most cost-effective or 
safest and progressing if necessary to more costly or risky drug therapy. 
5 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2011, 
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. 
8 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2014, 
OEI-05-14-00170, June 2014. 
9 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2015, 
OEI-05-15-00120, June 2015. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 3  Andrew M. Slavitt 
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.10  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 February 
2016, approximately 40.8 million of the 56.2 million Medicare beneficiaries were 
enrolled in a Part D plan. 
 
Part D plans are administered by private companiesknown as plan sponsorsthat 
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.  In 2016, plan 
sponsors offer 3,116 unique Part D plans, with many plan sponsors offering multiple 
Part D plans. 
 
Dual Eligibles Under Medicare Part D 
Approximately 10.3 million Medicare beneficiaries are dual eligibles.  For about 
7.7 million dual eligibles, referred to as full-benefit dual eligibles, Medicaid provides 
full Medicaid benefits, including Medicaid-covered services, and may also assist 
beneficiaries with premiums and cost-sharing for Medicare fee-for-service or Medicare 
managed care.11  For other dual eligibles, Medicaid does not provide Medicaid-covered 
services, but provides assistance with beneficiaries 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.12  
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.13  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.14   
                                                 
10 MMA, P.L. No. 108-173  101, Social Security Act,  1860D-1(a). 
11 Centers for Medicare & Medicaid Services, Medicare-Medicaid Enrollee State and County Enrollment 
Snapshots, Updated Quarterly (June 2015).  Accessed at https://www.cms.gov/Medicare-Medicaid-
Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-
Office/Analytics.html on March 22, 2016. 
12 Kaiser Family Foundation, Medicares Role for Dual Eligible Beneficiaries.  Accessed at 
http://www.kff.org/medicare/upload/8138-02.pdf on March 22, 2016. 
13 Ibid. 
14 MMA, P.L. No. 108-173  101, Social Security Act,  1860D-1(a). 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 4  Andrew M. Slavitt 
 
Medicare covers Part D plan premiums for dual eligibles up to a set benchmark.  The 
benchmark is a statutorily defined amount that is based on the average premium amounts 
for Part D plans for each region.15, 16  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.17   
 
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.18  The PDPs to which CMS assigns dual eligibles must meet certain 
requirements, such as having a premium at or below the regional benchmark amount and 
offering basic prescription drug coverage (or equivalent).19  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 Part D plans at any time to find plans that cover the prescription drugs they 
require.20  When dual eligibles change plans, their prescription drug coverage under the 
new Part D plan 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.21  For dual 
eligibles who were randomly assigned to their current PDPs, CMS chooses new PDPs 
that will have premiums at or below the regional benchmark premium.22  For dual 
eligibles who elected their current Part D plans, CMS notifies them that their plans will 
have premiums above the regional benchmark premium.  For 2016, CMS reported 
reassigning approximately 501,000 Medicare beneficiaries, including but not exclusively 
dual eligibles, because of premium increases. 
 
 
                                                 
15 Social Security Act,  1860D-14(b); 42 CFR  423.780(b)(2)(i).  
16 Dual eligibles residing in territories are not eligible to receive cost-sharing assistance from Medicare.  
With this being the case, there are no benchmarks for Part D plans offered in the territories.  Social Security 
Act,  1860D-14(a)(3)(F).   
17 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.  Patient Protection and Affordable Care Act (ACA), P.L. No. 111-148 
 3303, Social Security Act,  1860D-14(a)(5).  For 2014, CMS set the de minimis amount at $2 above the 
regional benchmark.  
18 CMS, PDBM, ch. 3,  40.1.4. 
19 Ibid.  
20 Ibid.,  30.3.2.  In general, Medicare beneficiaries can switch Part D plans only once a year during a 
defined enrollment period.  
21 Ibid.,  40.1.5.  
22 Ibid. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 5  Andrew M. Slavitt 
 
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 plan sponsors needs to contain costs.  Generally, a formulary must include at least 
two drugs in each therapeutic category or class.23, 24  In addition, Part D plans must 
include Part D-covered drugs in certain categories and classes.25 
 
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 that Part D plans make regarding individual 
formularies, certain categories of drugs are excluded from Medicare Part D prescription 
drug coverage as mandated by the MMA.26  For example, prescription vitamins, 
prescription mineral products, and nonprescription drugs are excluded from Part D 
prescription drug coverage.27   
 
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 such coverage.28, 29 
 
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, as 
well as all drugs in specified therapeutic categories or classes.30  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.31 
                                                 
23 CMS, PDBM, ch. 6,  30.2.1.   
24 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.  
25 Social Security Act,  1860D-4(b)(3)(G). 
26 MMA, P.L. No. 108-173  101, Social Security Act,  1860D-2(e).  
27 Social Security Act  1860D-2(e)(2), 1927(d)(2). 
28 ACA, P.L. No. 111-148  2502, Social Security Act,  1927(d). 
29 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 March 22, 2016. 
30 CMS, PDBM, ch. 6,  30.2.7.   
31 Ibid.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 6  Andrew M. Slavitt 
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.32, 33, 34 
 
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.35  If their plans make negative determinations, 
beneficiaries have the right to appeal.36  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.37  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.38 
                                                 
32 Ibid.,  30.2.2. 
33 Ibid.,  30.2.7. 
34 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.   
35 CMS, PDBM, ch. 18,  30.1 and 30.2.  
36 Ibid.,  60.1.  
37 Ibid., ch. 6,  30.4.4.  
38 OIG, Dual Eligibles Transition:  Part D Formularies Inclusion of Commonly Used Drugs, 
OEI-05-06-00090, January 2006.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 7  Andrew M. Slavitt 
In 2011, OIG issued the first annual mandated report examining dual eligibles access to 
drugs under Medicare Part D.39  We have released an annual mandated report each year 
since then.40, 41, 42, 43  The current report is the sixth report released. 
 
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 2016.  As part of our assessment, we 
included dual eligibles enrollment data from February 2016, the most recent enrollment 
data available from CMS at the time of our study.  We also compared the results of our 
2016 study with those of our 2015 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)i.e., the 2012 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 that we identified using the MCBS, 198 are eligible 
for coverage under Part D.  In this report, we refer to these 198 Part D-eligible 
high-utilization drugs as commonly used drugs. 
 
The list of 200 drugs with the highest utilization by dual eligibles referenced in this 
2016 report is similar but not identical to the list of drugs referenced in the 2015 report.  
Specifically, 182 of the 200 drugs (91 percent) listed in the 2015 report are also listed in 
this 2016 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.   
 
                                                 
39 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2011, 
OEI-05-10-00390, April 2011. 
40 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2012, 
OEI-05-12-00060, June 2012. 
41 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2013, 
OEI-15-13-00090, June 2013. 
42 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2014, 
OEI-05-14-00170, June 2014. 
43 OIG, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2015, 
OEI-05-15-00120, June 2015. 
44 Ibid. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 8  Andrew M. Slavitt 
We also went beyond the ACAs mandate in the 2013, 2014, 2015, and 2016 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 the 2012 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 
2012 MCBS Cost and Use data are the most recent data available.   
 
The MCBS is a continuous, multipurpose survey that CMS conducts 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 2012, the MCBS surveyed 11,299 Medicare beneficiaries, of whom 2,244 were dual 
eligibles who had used prescription drugs during the year (out of 2,484 dual-eligible 
survey respondents). 
 
First Databank National Drug Data File.  We used the December 2015 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 that 
contains informationsuch as drug name, therapeutic category or class, and the unique 
combination of active ingredientsfor each drug as defined by a National Drug Code 
(NDC).45 
 
Part D plan data.  In January 2016, we collected from CMS the formulary data and the 
plan data for Part D plans operating in 2016.  The formulary data includes Part D plans 
formularies and utilization management tools for plans operating in 2016.  In 2016, there 
are 374 unique formularies offered by 3,116 Part D plans.  The plan data provides 
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 2016 enrollment data for Part D plans.  These data provide the number 
of dual eligibles enrolled in each Part D plan as of February 2016.   
 
   
                                                 
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:  2016 (OEI-05-16-00090)  Page 9  Andrew M. Slavitt 
Determining the Most Commonly Used Drugs 
To determine the drugs most commonly used by dual eligibles, we took the following 
steps: 
 
1.  We created a list of all drugs reported by dual eligibles surveyed in the 
2012 MCBS.  We excluded respondents from territories because they are not 
eligible to receive cost-sharing assistance under Part D.  The MCBS listed 
167,848 drug events for 2,244 dual eligibles who did not reside in territories.46 
 
2.  We 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 brand-name drug Prozac) has only one entry on our list, 
covering all strengths of both the brand-name drug Prozac and the available 
generic versions of fluoxetine hydrochloride.  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 167,848 drug events associated with 868 drugs.   
 
3.  We ranked the 868 drugs by frequency of utilization, weighting the drug-event 
information from MCBS by sample weight.   
 
4.  We selected the 200 drugs with the highest utilization by dual eligibles.  For a full 
list of the top 200 drugs, see Appendix B. 
 
5.  We removed all drugs not covered under Part D.  Of the 200 drugs with the 
highest utilization, 198 are eligible under Part D.  One fell into a drug category 
excluded under Part D, and one is no longer prescribed in the form taken by 
beneficiaries surveyed in the 2012 MCBS.  For details on these two drugs, see 
Appendix C. 
 
Formulary Analysis 
We analyzed the 374 unique Part D plan formularies to determine their rates of inclusion 
of the 198 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 198 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 an MCBS survey response indicating that the responding 
beneficiary took a specific drug at least once in 2012.  For example, 1 MCBS survey respondent reported 
taking rosuvastatin calcium (Crestor) 12 times in 2012.  We counted this beneficiary/drug combination as 
12 drug events.  
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 10  Andrew M. Slavitt 
374 formularies covered each drug.  We considered a drug to have a low rate of inclusion 
if it was included by less than 75 percent 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 198 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 198 drugs that we reviewed.  The tools that we 
reviewed are prior authorization, quantity limits, and step therapy. 
 
To determine the extent to which the 198 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 198 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 
analysis of utilization management tools by both dual-eligible enrollment and Medicare 
enrollment.  To do this, we applied enrollment data from February 2016 to Part D plans 
available in 2016.   
 
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 2012 account for 88 percent of all prescriptions dispensed 
to the dual-eligible respondents in the 2012 MCBS.    
 
Because the lists of commonly used drugs in the 2015 and 2016 reports are not identical, 
the changes in rates of inclusion by formularies and in application of utilization 
management tools between 2015 and 2016 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 on the list in our 2015 report were also 
on the list in this 2016 report. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 11  Andrew M. Slavitt 
 
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 88 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 374 unique formularies used by Part D plans in 2016, 6 formularies 
include 100 percent of the commonly used drugs.  At the other end of the inclusion range, 
six formularies include 88 percent of the commonly used drugs.  Figure 1 provides 
a breakdown of the formularies inclusion rates for the drugs most commonly used by 
dual eligibles.  CMS generally requires Part D plan formularies to include at least two 
drugsrather than all drugsin 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. 
 
Figure 1:  More than two-thirds of Part D plan formularies cover at least 
96 percent of the drugs commonly used by dual eligibles. 
79
77
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88% 89% 90% 91% 92% 93% 94% 95% 96% 97% 98% 99% 100%
Percentage of commonly used drugs included in formulary
 
 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2016.
 
Part D plan formularies rate of inclusion of the drugs commonly used by dual eligibles 
in 2016 is similar to that of 2015.  The average rate of inclusion increased slightly 
between 2015 and 2016, from 95 percent to 96 percent.  The range of inclusion rates in 
2015 and 2016 are almost the samein 2015, the rates of inclusion ranged from 86 to 
100 percent of the drugs commonly used by dual eligibles, and in 2016, they ranged from 
88 to 100 percent. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 12  Andrew M. Slavitt 
 
Nationally, PDP and MA-PD formularies have similar rates of inclusion of the drugs 
commonly used by dual eligibles, averaging 96 percent and 97 percent, respectively.  
For PDP formularies, the rates of inclusion ranged from 88 to 99 percent; for MA-PD 
formularies, they ranged from 88 to 100 percent.  Fifteen formularies4 percent of the 
374 unique formularies used by Part D plans in 2016are offered by both PDPs and 
MA-PDs. 
 
Regionally, all dual eligibles have the choice of a Part D plan that includes at least 
97 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 
includes at least 97 percent of these drugs.  Appendix D provides a breakdown of 
formularies rates of inclusion of the drugs by PDP and MA-PD region. 
 
On average, formularies for Part D plans with premiums below the regional benchmark 
include 96 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, 
such plans.  For drugs commonly used by dual eligibles, formularies for such plans have 
rates of inclusion that range from 88 percent to 100 percent.  Approximately 85 percent 
of dual eligibles are enrolled in Part D plans with premiums below the regional 
benchmark. 
 
Almost all 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 10.2 million dual 
eligibles enrolled in Part D plans, nearly 100 percent are enrolled in Part D plans that use 
formularies that include at least 90 percent of the commonly used drugs.  Less than 
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  136,868  1% 
95% to 99% of commonly used drugs  3,802,667  37% 
90% to 94% of commonly used drugs  6,213,107  61% 
85% to 89% of commonly used drugs  45,487  <1% 
     Total  10,198,129  100%* 
 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles and dual eligibles 
enrollment, 2016. 
*Percentages do not add to 100 percent because of rounding. 
 
The percentage of dual eligibles enrolled in Part D plans that include at least 90 percent 
of the drugs commonly used by dual eligibles increased from 94 percent in 2015 to nearly 
100 percent in 2016.   
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 13  Andrew M. Slavitt 
 
 
Sixty-Eight 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 can be confident 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 37 percent to 100 percent.  At one end of the range, 
there is a drug that is included in 37 percent of Part D plan formularies, and at the other 
end, 134 drugs are included in all plan formularies.  The average rate of inclusion by 
formularies is 96 percent.  Table 2 shows the rates at which formularies include the 
198 drugs.  Appendix B lists the 198 drugs and the rates at which formularies include 
them. 
 
Table 2:  Formularies Rates of Inclusion of Commonly Used Drugs 
Percentage of the 198 Commonly 
Percentage of the 374 Formularies  Used Drugs Included in 
Formularies 
68% 
100% 
(134 drugs) 
24% 
85% to 99% 
(47 drugs) 
4% 
76% to 84% 
(8 drugs) 
5% 
37% to 75% 
(9 drugs) 
100%* 
    Total 
(198 drugs) 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2016. 
*Percentages do not add to 100 percent because of rounding. 
 
The rates of formulary inclusion of the drugs commonly used by dual eligibles in 
2016 are similar to those in 2015.  The percentage of commonly used drugs included in 
all formularies increased slightly between 2015 and 2016, from 66 percent to 68 percent. 
 
Part D plan formularies include certain drugs less frequently than others.  Of the 
commonly used drugs, 5 percent (nine drugs) are included by less than 75 percent of 
Part D plan formularies.  Table 3 provides the percentage of formularies covering each of 
these nine drugs.   
 
The drugs that make up this group include both brand-name and generic drugs, and are 
used to treat a variety of primary indications.  Four of the nine drugs are brand-name 
drugs, which are typically more costly than generic drugs.  As for the primary 
indications, 3 of the 9 drugs are used for diabetic therapy, 2 of the 11 drugs are muscle 
relaxants, and the remaining drugs treat a variety of conditions, including gastrointestinal 
conditions. 
 
   
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 14  Andrew M. Slavitt 
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 
Insulin aspart  Diabetes  74% 
Stomach and intestinal ulcers, erosive esophagitis, 
Lansoprazole  73% 
excessive stomach acid, Zollinger-Ellison syndrome 
Dutasteride  Symptomatic benign prostatic hyperplasia  69% 
Dexlansoprazole  Gastroesophageal reflux disease  64% 
Insulin lispro  Diabetes  61% 
Methocarbamol  Musculoskeletal pain  56% 
Dyspepsia, peptic ulcer disease, gastroesophageal reflux 
Esomeprazole magnesium  56% 
disease, Zollinger-Ellison syndrome 
Glyburide  Diabetes  46% 
Carisoprodol  Musculoskeletal pain  37% 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2016. 
The drugs in the shaded rows also had low formulary inclusion rates in 2015. 
 
Although Part D formularies frequently omit these 9 drugs, they all cover other drugs in 
the same therapeutic classes.  For these 9 drugs, 100 percent of formularies cover at least 
1 drug in the same therapeutic class that is also on the list of 198 drugs commonly used 
by dual eligibles. 
  
The number of drugs included by less than 75 percent of formularies decreased from 
11 in 2015 to 9 in 2016.  There are five drugs with low inclusion rates in 2016 that were 
also on the list of commonly used drugs with low inclusion rates in our 2015 report; we 
note these five drugs in Table 3.  Two of these five drugs were also on the list of drugs 
with low inclusion rates in our 2014 report.   
 
There are multiple potential reasons why a commonly used drug might be included by 
less than 75 percent of formularies: 
 
  Two of these drugscarisoprodol and methocarbamolare on CMSs list of 
Part D medications that are high-risk for the elderly.47    
  The two drugs above and a third drugglyburideare listed by the American 
Geriatrics Society as being potentially inappropriate for older adults.48 
 
                                                 
47 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 drug that is listed as being high risk for the elderly is one that has a 
high risk of serious side effects in that population.  CMS uses its prescription data and 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 measures of Part D patient safety so that Medicare 
beneficiaries can make informed decisions in choosing Part D plans for their prescription drug coverage.  
National Committee on Quality Assurance, HEDIS 2012 NDC List.  Accessed at 
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/ 
MemoPatientSafetyMeasures_071610.pdf on March 22, 2016. 
48 The American Geriatrics Society, American Geriatrics Society 2015 Updated Beers Criteria for 
Potentially Inappropriate Medication Use in Older Adults, 2015. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 15  Andrew M. Slavitt 
If a particular drug has a low rate of inclusion by formularies, a dual eligible may need 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 plans with formularies that include their drugs, with the 
new coverage becoming effective the following month.50 
 
The Percentage of Commonly Used Drugs Subject to Utilization Management Tools 
by Plan Formularies Decreased Slightly Between 2015 and 2016 
For the unique drugs that compose the list of commonly used drugs, the percentage 
subject to utilization management tools by Part D plan formularies decreased slightly 
from an average of 29 percent in 2015 to an average of 28 percent in 2016.  Formularies 
for plans with premiums below and those with premiums above the regional benchmarks 
had relatively similar percentages of drugs25 percent and 29 percent, respectively
that 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 2015 and 2016. 
 
Table 4:  Part D Plan Formularies Application of Utilization Management Tools to 
Commonly Used Drugs, 2015 and 2016 
Percentage of Unique Drugs  Number of  Number of 
Percentage of  Percentage of 
to Which Utilization  2015 Part D  2016 Part D 
2015 Part D Plan  2016 Part D Plan 
Management Tools Are  Plan  Plan 
Formularies  Formularies 
Applied  Formularies  Formularies 
Greater than 40%  49  14%  22  6% 
30% to 39%  137  40%  189  50% 
20% to 29%  66  19%  59  16% 
10% to 19%  65  19%  74  20% 
Less than 10%  24  7%  30  8% 
     Totals  341  100%*  374  100% 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2016. 
* Percentages do not add to 100 percent because of rounding. 
 
Although utilization management tools can restrict beneficiaries access to drugs, they are 
important tools for managing costs in Medicare and ensuring appropriate utilization of 
drugs.  For example, in 2013, CMS set forth expectations for reviews of opioid 
overutilization to help ensure that opioids are appropriately prescribed and used.  As 
a result, formularies application of utilization management controls to oxycodone 
HCl/acetaminophen drugs increased by 30 percent in 2013.51 
 
                                                 
49 CMS, PDBM, ch. 18,  30.2.2. 
50 Ibid., ch. 3,  30.3.2. 
51 CMS, Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D, 
September 6, 2012.  Accessed at https://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-
toImprovingDURcontrols.pdf on March 22, 2016. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 16  Andrew M. Slavitt 
The percentage of drugs subject to quantity limits or step therapy decreased slightly from 
2015 to 2016, while the percentage of drugs subject to prior authorization remained the 
same.  Formularies use of quantity limits and use of step therapy each decreased by 
1 percentfrom 25 to 24 percent and from 2 to 1 percent of unique drugs, respectively.  
The percentage of unique drugs for which formularies required prior authorization was 
4 percent in both 2015 and 2016.  
 
The rate at which plan formularies apply specific utilization management tools varies 
widely.  In 2016, 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 between 0 and 
43 percent of unique drugs, require prior authorization for between 0 and 13 percent, and 
require step therapy for between 0 and 12 percent.  
 
Looking at enrollment across plans provides a slightly different picture than looking only 
at plans themselves.  On average, plan formularies in 2016 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 2016, the median plan 
weighted by dual-eligible enrollment applies such tools to 32 percent of unique drugs; in 
2015, the figure was 35 percent.  Similarly, the median plan weighted by overall 
Medicare enrollment applies these tools to 31 percent of unique drugs in 2016; in 
2015, the figure was 34 percent.   
 
Both dual eligibles and Medicare beneficiaries overall tend to be enrolled in plans with 
formularies that apply utilization management tools to between 30 and 47 percent of 
unique drugs.  In 2016, 80 percent of dual eligibles and 73 percent of Medicare 
beneficiaries overall were enrolled in plans with formularies in this range.  Table 5 shows 
enrollment in Part D plans by dual eligibles and Medicare beneficiaries, as broken down 
by the percentages at which the plans formularies apply utilization management tools.   
 
Table 5:  Beneficiary Enrollment in Part D Plans by Application of Utilization 
Management Tools to Commonly Used Drugs, 2015 and 2016 
Percentage of Unique  Percentage  Percentage  Percentage  Percentage 
Drugs to Which Plan  of Dual  of Medicare  of Dual  of Medicare 
Formularies Apply  Eligibles  Beneficiaries  Eligibles  Beneficiaries 
Utilization Management  Enrolled,  Enrolled,  Enrolled,  Enrolled, 
Tools   2015  2015  2016  2016 
Greater than 40%  8%  16%  1%  1% 
30% to 39%  54%  41%  79%  72% 
20% to 29%  32%  34%  14%  18% 
10% to 19%  4%  5%  3%  5% 
Less than 10%  2%  3%  2%  4% 
     Totals  100%  100%*  100%*  100% 
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2016. 
* Percentages do not add to 100 percent because of rounding. 
 
   
 
 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 17  Andrew M. Slavitt 
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 plan sponsors 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 nine drugs that this 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 88 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 198 drugs commonly used by dual eligibles are largely unchanged 
compared with those from OIGs 2015 report.  Part D plan formularies include roughly 
the same percentage of these commonly used drugs in 2016 as they did in 2015.  
Enrollment in plans that cover at least 90 percent of unique drugs increased, with nearly 
100 percent of dual eligibles enrolled in such plans in 2016 compared to 94 percent in 
2015.     
 
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 and produce annual reports on 
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 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-05-16-00090 in all correspondence. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 18  Andrew M. Slavitt 
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:  2016 (OEI-05-16-00090)  Page 19  Andrew M. Slavitt 
APPENDIX B 
 
Commonly Used Drugs and Rates of Inclusion by Formularies 
 
The 200 Drugs With the Highest Utilization by Dual Eligibles  
*Sample is from the 2012 MCBS.  Projections and confidence intervals are derived from its survey methodology. 
Number of 
Projected  Percentage of 
Sample  95-Percent Confidence  Formularies 
Generic Name  Drug  Formularies 
Size*  Interval*  Including 
Events*  Including Drug 
Drug 
Simvastatin  4,085  20,275,845  18,246,78822,304,903  374  100% 
Lisinopril  4,146  20,105,037  17,883,00522,327,069  374  100% 
Omeprazole  4,277  17,651,028  15,907,56419,394,492  373  100% 
Levothyroxine sodium  3,875  16,391,504  14,506,69918,276,310  374  100% 
Hydrocodone/acetaminophen  4,335  15,724,258  13,700,63317,747,884  374  100% 
Furosemide  3,594  15,682,269  13,969,19817,395,341  374  100% 
Metformin HCl  3,053  15,402,973  13,342,09317,463,852  374  100% 
Amlodipine besylate  3,084  14,334,829  12,552,77516,116,883  374  100% 
Potassium chloride  2,535  9,847,651  8,425,38111,269,921  374  100% 
Gabapentin  2,195  9,659,579  7,744,86711,574,290  374  100% 
Atorvastatin calcium  1,892  9,469,703  8,032,97810,906,428  374  100% 
Metoprolol tartrate  2,161  9,465,474  8,198,82710,732,121  374  100% 
Hydrochlorothiazide  1,684  8,538,793  7,204,2279,873,358  374  100% 
Warfarin sodium  2,143  8,176,792  6,782,6359,570,949  374  100% 
Albuterol sulfate  1,809  8,051,430  6,601,0899,501,772  374  100% 
Esomeprazole magnesium  1,623  7,345,547  5,669,7489,021,345  208  56% 
Tramadol HCl  1,814  7,033,265  5,908,2068,158,324  374  100% 
Citalopram hydrobromide  1,743  7,028,557  5,999,8408,057,274  374  100% 
Clopidogrel bisulfate  1,420  6,884,688  5,592,0488,177,329  374  100% 
Atenolol  1,341  6,622,365  5,452,7387,791,992  374  100% 
Zolpidem tartrate  1,479  6,486,938  5,054,3257,919,552  363  97% 
Carvedilol  1,354  6,189,667  5,070,6877,308,647  374  100% 
Insulin glargine,hum.rec.anlog  1,299  5,924,792  4,861,2446,988,340  361  97% 
Promethazine HCl  2,023  5,868,471  4,226,0807,510,861  372  99% 
Glipizide  1,064  5,847,097  4,635,2107,058,983  374  100% 
Fluticasone/salmeterol  1,111  5,800,120  4,224,9837,375,257  337  90% 
Oxycodone  1,474  5,676,415  4,586,5696,766,261  374  100% 
HCl/acetaminophen 
Metoprolol succinate  1,120  5,665,210  4,616,3246,714,096  373  100% 
Ranitidine HCl  1,409  5,482,639  4,145,8626,819,416  374  100% 
Losartan potassium  1,153  5,482,241  4,424,4766,540,005  374  100% 
Trazodone HCl  1,285  5,420,884  4,236,8376,604,931  374  100% 
Clobetasol propionate  1,232  5,343,963  3,259,8677,428,059  368  98% 
Sertraline HCl  1,329  5,328,104  4,285,1126,371,097  374  100% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 20  Andrew M. Slavitt 
The 200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of 
Projected  Percentage of 
Sample  95-Percent Confidence  Formularies 
Generic Name  Drug  Formularies 
Size*  Interval*  Including 
Events*  Including Drug 
Drug 
Alendronate sodium  1,134  5,059,020  4,027,9786,090,062  374  100% 
Valsartan  999  4,988,907  3,709,0416,268,773  364  97% 
Quetiapine fumarate  1,580  4,695,543  3,580,8225,810,265  374  100% 
Pravastatin sodium  1,055  4,497,382  3,599,8135,394,952  374  100% 
Fluticasone propionate  1,031  4,475,369  3,782,7975,167,942  374  100% 
Montelukast sodium  983  4,241,912  3,276,6545,207,171  374  100% 
Prednisone  987  4,140,130  3,299,8914,980,370  374  100% 
Rosuvastatin calcium  862  4,079,698  3,143,9925,015,404  326  87% 
Donepezil HCl  1,067  3,945,615  3,220,9464,670,284  374  100% 
Risperidone  1,320  3,931,788  3,128,0464,735,529  374  100% 
Bupropion HCl  880  3,854,353  2,640,7275,067,980  374  100% 
Isosorbide mononitrate  797  3,805,846  3,135,3064,476,386  374  100% 
Clonidine HCl  765  3,747,550  2,494,4395,000,661  374  100% 
Tamsulosin HCl  741  3,702,932  2,870,6554,535,209  374  100% 
Lovastatin  760  3,603,172  2,680,2554,526,090  373  100% 
Aripiprazole  915  3,588,383  2,471,1054,705,661  374  100% 
Cyclobenzaprine HCl  884  3,576,109  2,862,7224,289,496  288  77% 
Duloxetine HCl  829  3,455,834  2,612,0264,299,643  374  100% 
Pantoprazole sodium  745  3,437,474  2,677,1594,197,789  364  97% 
Allopurinol  713  3,403,401  2,647,1984,159,603  374  100% 
Escitalopram oxalate  881  3,387,426  2,551,3904,223,461  374  100% 
Ibuprofen  953  3,311,577  2,684,3843,938,770  374  100% 
Fluoxetine HCl  793  3,256,783  2,506,9274,006,640  374  100% 
Alprazolam  852  3,243,748  2,306,1614,181,334  325  87% 
Oxycodone HCl  923  3,211,833  2,344,8564,078,811  374  100% 
Diltiazem HCl  804  3,112,978  2,356,1103,869,845  374  100% 
Glimepiride  596  3,102,504  2,097,4294,107,579  374  100% 
Azithromycin  826  2,990,930  2,651,7763,330,084  374  100% 
Divalproex sodium  1,147  2,956,347  2,371,6993,540,994  374  100% 
Memantine HCl  820  2,946,246  2,305,4193,587,073  374  100% 
Nystatin  778  2,877,573  1,728,1674,026,980  374  100% 
Pregabalin  620  2,874,390  1,945,8833,802,897  374  100% 
Olanzapine  826  2,743,691  1,746,9753,740,406  374  100% 
Famotidine  598  2,741,416  2,001,6033,481,230  373  100% 
Amitriptyline HCl  648  2,732,645  2,025,5663,439,723  374  100% 
Sitagliptin phosphate  563  2,731,020  1,929,9373,532,103  363  97% 
Tiotropium bromide  561  2,700,930  2,048,6313,353,230  320  86% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 21  Andrew M. Slavitt 
The 200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of 
Projected  Percentage of 
Sample  95-Percent Confidence  Formularies 
Generic Name  Drug  Formularies 
Size*  Interval*  Including 
Events*  Including Drug 
Drug 
Meloxicam  641  2,699,758  2,079,8603,319,656  373  100% 
Ketoconazole  778  2,678,585  1,642,0813,715,089  374  100% 
Mirtazapine  693  2,629,860  1,932,9773,326,744  374  100% 
Nifedipine  467  2,620,445  1,841,0873,399,804  360  96% 
Lisinopril/hydrochlorothiazide  561  2,602,432  2,034,1293,170,735  374  100% 
Lamotrigine  812  2,568,810  1,524,9013,612,719  374  100% 
Levetiracetam  774  2,542,145  1,772,6303,311,661  374  100% 
Clonazepam  696  2,474,602  1,754,4673,194,736  374  100% 
Enalapril maleate  551  2,442,608  1,834,2603,050,956  374  100% 
Triamterene/  484  2,409,224  1,777,6593,040,789  374  100% 
hydrochlorothiazide 
Paroxetine HCl  608  2,399,150  1,706,2983,092,003  374  100% 
Celecoxib  482  2,386,463  1,634,4293,138,497  341  91% 
Benztropine mesylate  796  2,344,725  1,666,4263,023,025  373  100% 
Carbamazepine  711  2,291,674  1,547,2403,036,107  374  100% 
Ciprofloxacin HCl  561  2,201,817  1,879,7692,523,865  374  100% 
Spironolactone  530  2,167,379  1,706,0242,628,734  374  100% 
Nitroglycerin  489  2,159,899  1,556,8442,762,953  374  100% 
Diclofenac sodium  459  2,071,649  1,535,7082,607,591  374  100% 
Valsartan/hydrochlorothiazide  411  2,043,602  1,418,4122,668,792  365  98% 
Digoxin  563  2,017,627  1,397,3472,637,908  374  100% 
Latanoprost  451  1,941,504  1,429,8722,453,136  374  100% 
Topiramate  676  1,919,140  1,225,7772,612,502  374  100% 
Morphine sulfate  482  1,917,895  1,323,9032,511,887  374  100% 
Fluocinonide  517  1,914,945  984,5792,845,310  373  100% 
Polyethylene glycol 335d  563  1,911,548  1,456,5162,366,580  374  100% 
Sulfamethoxazole/  575  1,882,925  1,565,5742,200,276  374  100% 
trimethoprim 
Lorazepam  478  1,872,334  1,385,5922,359,076  374  100% 
Ipratropium/albuterol sulfate  475  1,863,411  1,265,0892,461,734  361  97% 
Carbidopa/levodopa  469  1,847,813  1,150,9582,544,668  374  100% 
Fenofibrate nanocrystallized  393  1,802,940  1,311,2342,294,646  355  95% 
Glyburide  333  1,800,905  1,292,0572,309,754  171  46% 
Levofloxacin  450  1,776,547  1,439,4012,113,694  374  100% 
Oxybutynin chloride  465  1,772,254  1,130,9862,413,522  374  100% 
Venlafaxine HCl  565  1,769,289  1,293,0932,245,485  374  100% 
Verapamil HCl  386  1,768,870  1,232,5682,305,172  374  100% 
Pioglitazone HCl  350  1,765,584  1,267,9582,263,210  374  100% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 22  Andrew M. Slavitt 
The 200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of 
Projected  Percentage of 
Sample  95-Percent Confidence  Formularies 
Generic Name  Drug  Formularies 
Size*  Interval*  Including 
Events*  Including Drug 
Drug 
Naproxen  481  1,712,919  1,305,6372,120,202  374  100% 
Cephalexin  461  1,708,905  1,354,5462,063,263  374  100% 
Insulin aspart  438  1,697,897  1,236,2822,159,511  278  74% 
Meclizine HCl  354  1,694,107  1,166,4382,221,776  374  100% 
Cinacalcet HCl  273  1,686,744  228,7513,144,737  374  100% 
Benazepril HCl  314  1,662,487  1,061,7792,263,195  373  100% 
Amoxicillin  449  1,645,349  1,440,4301,850,269  374  100% 
Ezetimibe  315  1,630,531  1,137,3722,123,691  373  100% 
Hydralazine HCl  352  1,626,562  1,040,3542,212,770  374  100% 
Losartan/hydrochlorothiazide  323  1,616,723  1,126,2092,107,237  374  100% 
Methocarbamol  332  1,604,238  957,8522,250,624  210  56% 
Carisoprodol  468  1,569,542  1,069,9162,069,169  138  37% 
Lansoprazole  300  1,517,331  937,7322,096,931  273  73% 
Lidocaine  392  1,497,702  1,062,2291,933,176  374  100% 
Baclofen  432  1,496,342  901,7592,090,925  374  100% 
Propranolol HCl  441  1,466,579  989,9031,943,256  374  100% 
Tizanidine HCl  465  1,402,405  922,1521,882,657  374  100% 
Buspirone HCl  345  1,392,828  771,7202,013,936  374  100% 
Lactulose  352  1,376,489  858,0831,894,894  374  100% 
Brimonidine tartrate  270  1,364,643  814,0361,915,250  374  100% 
Omega-3 acid ethyl esters  337  1,340,484  863,7541,817,215  350  94% 
Methadone HCl  233  1,334,501  668,8122,000,191  373  100% 
Metoclopramide HCl  272  1,311,286  790,7711,831,801  374  100% 
Ropinirole HCl  318  1,304,881  795,6811,814,080  374  100% 
Phenytoin sodium extended  414  1,299,826  893,2471,706,406  374  100% 
Budesonide/formoterol  297  1,282,394  897,1951,667,593  287  77% 
fumarate 
Timolol maleate  251  1,278,484  801,8321,755,136  374  100% 
Hydrocortisone  279  1,276,518  768,3571,784,678  374  100% 
Travoprost  325  1,223,842  898,8381,548,847  332  89% 
Olopatadine HCl  288  1,210,924  776,9191,644,928  330  88% 
Hydroxyzine HCl  296  1,208,115  813,7931,602,437  298  80% 
Bimatoprost  206  1,206,009  747,3061,664,713  353  94% 
Insulin detemir  325  1,203,894  807,2161,600,572  310  83% 
Ziprasidone HCl  331  1,183,365  639,9471,726,783  374  100% 
Doxazosin mesylate  253  1,166,572  705,7081,627,436  374  100% 
Insulin lispro  243  1,165,251  612,8421,717,661  229  61% 
Diazepam  336  1,163,773  805,7881,521,758  374  100% 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 23  Andrew M. Slavitt 
The 200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of 
Projected  Percentage of 
Sample  95-Percent Confidence  Formularies 
Generic Name  Drug  Formularies 
Size*  Interval*  Including 
Events*  Including Drug 
Drug 
Pramipexole di-HCl  269  1,163,159  716,8591,609,460  374  100% 
Dexlansoprazole  255  1,154,307  605,9891,702,624  240  64% 
Acetaminophen with codeine  324  1,146,119  835,5141,456,724  374  100% 
Finasteride  193  1,142,207  645,8011,638,614  374  100% 
Metronidazole  277  1,082,251  740,2941,424,207  374  100% 
Estrogens, conjugated  207  1,062,210  680,5811,443,839  307  82% 
Ramipril  216  1,044,656  618,6601,470,651  374  100% 
Mometasone furoate  273  1,041,955  738,0621,345,847  373  100% 
Doxycycline hyclate  306  1,039,974  803,0521,276,896  374  100% 
Gemfibrozil  317  1,002,452  655,3981,349,505  374  100% 
Insulin regular, human  321  997,047  448,3811,545,713  374  100% 
Clozapine  377  996,800  256,7961,736,805  374  100% 
Amoxicillin/potassium clav  296  992,326  798,7421,185,910  374  100% 
Fentanyl  283  950,958  630,4401,271,475  374  100% 
Fenofibrate  200  947,241  530,0411,364,441  373  100% 
Terazosin HCl  196  944,375  600,1071,288,642  374  100% 
Quinapril HCl  176  941,788  521,2521,362,324  371  99% 
Amlodipine  210  938,298  638,2821,238,313  359  96% 
besylate/benazepril 
Tolterodine tartrate  218  934,963  602,6581,267,269  358  96% 
Insulin nph hum/reg insulin  223  926,025  503,3221,348,729  374  100% 
hm 
Fluconazole  268  906,521  631,4791,181,562  374  100% 
Sucralfate  252  899,714  608,7361,190,692  374  100% 
Niacin  249  884,662  476,2451,293,079  370  99% 
Colchicine  183  874,820  496,0961,253,544  374  100% 
Solifenacin succinate  189  861,786  578,3761,145,197  306  82% 
Megestrol acetate  226  860,045  569,0491,151,041  374  100% 
Ciclopirox olamine  190  846,025  291,4801,400,570  361  97% 
Calcitriol  181  844,443  510,5741,178,312  374  100% 
Hydroxychloroquine sulfate  227  843,974  546,0861,141,862  374  100% 
Dicyclomine HCl  258  835,905  510,7201,161,090  357  95% 
Sevelamer carbonate  181  834,843  473,1551,196,532  362  97% 
Dorzolamide HCl/  183  820,248  535,8271,104,669  368  98% 
timolol maleate 
Raloxifene HCl  170  817,458  404,8261,230,090  374  100% 
Ergocalciferol (vitamin D)  238  815,762  577,4441,054,081  0  0%** 
2
Dutasteride  175  812,367  421,1631,203,571  258  69% 
Cyclosporine  206  811,780  542,0871,081,473  374  100% 
**See Appendix C. 
continued on next page 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 24  Andrew M. Slavitt 
The 200 Drugs With the Highest Utilization by Dual Eligibles, continued 
Number of 
Projected  Percentage of 
Sample  95-Percent Confidence  Formularies 
Generic Name  Drug  Formularies 
Size*  Interval*  Including 
Events*  Including Drug 
Drug 
Ipratropium bromide  212  809,312  479,3061,139,318  374  100% 
Prednisolone acetate  186  793,727  589,346998,109  348  93% 
Clotrimazole/  215  793,462  607,917979,006  301  80% 
betamethasone dip 
Estradiol  152  785,815  436,4141,135,216  374  100% 
Primidone  200  780,692  193,8581,367,527  374  100% 
Torsemide  197  780,054  485,1861,074,923  365  98% 
Nitrofurantoin  192  773,126  516,9751,029,278  361  97% 
monohyd/m-cryst 
Albuterol  176  770,589  478,2251,062,953  0  0%** 
Sumatriptan succinate  146  767,599  -30,5011,565,698  374  100% 
Risedronate sodium  147  763,979  295,1761,232,781  294  79% 
0.9% sodium chloride  216  754,836  155,7201,353,952  372  99% 
Cilostazol  202  751,130  399,9431,102,317  374  100% 
Amiodarone HCl  149  750,614  391,6671,109,561  374  100% 
Chlorthalidone  150  735,530  370,4801,100,580  371  99% 
Doxepin HCl  202  724,154  404,2931,044,015  374  100% 
Mupirocin  204  697,884  520,300875,469  374  100% 
Ondansetron HCl  183  663,507  421,480905,535  374  100% 
Metolazone  127  657,608  251,5431,063,674  366  98% 
Clonidine  114  654,668  234,6161,074,720  336  90% 
Source:  OIG analysis of drugs commonly used by dual eligibles, 2016. 
**See Appendix C. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 25  Andrew M. Slavitt 
APPENDIX C 
 
Two 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 
Ergocalciferol (vitamin D)*  Vitamin or mineral product 
2
Source:  OIG analysis of formulary inclusion of drugs commonly used by dual eligibles, 2016. 
*These drugs were also on the 2015 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:  2016 (OEI-05-16-00090)  Page 26  Andrew M. Slavitt 
APPENDIX D 
 
Formulary Inclusion of Stand-Alone Prescription Drug Plans* and Medicare 
Advantage Prescription Drug Plans**, by Region 
 
Table D-1:  PDP Formularies Inclusion of Commonly Used Drugs, by PDP Region 
PDP  Number of  Average Rate of  Maximum 
State(s)  Minimum Rate 
Region  PDPs  Inclusion by Formularies  Rate 
1  Maine, New Hampshire  25  96%  93%  99% 
Connecticut, Massachusetts,  23  96%  93%  99% 
2 
Rhode Island, Vermont 
3  New York  19  96%  93%  99% 
4  New Jersey  22  96%  93%  99% 
Delaware, the District of  21  96%  93%  99% 
5 
Columbia, Maryland 
6  Pennsylvania, West Virginia  26  96%  93%  99% 
7  Virginia  25  96%  93%  99% 
8  North Carolina  23  96%  88%  99% 
9  South Carolina  24  96%  88%  99% 
10  Georgia  24  96%  93%  99% 
11  Florida  19  96%  93%  99% 
12  Alabama, Tennessee  24  96%  93%  99% 
13  Michigan  25  96%  93%  99% 
14  Ohio  24  96%  93%  99% 
15  Indiana, Kentucky  25  96%  93%  99% 
16  Wisconsin  25  95%  92%  99% 
17  Illinois  25  96%  88%  99% 
18  Missouri  25  96%  93%  99% 
19  Arkansas  25  96%  93%  99% 
20  Mississippi  21  96%  93%  99% 
21  Louisiana  22  96%  93%  99% 
22  Texas  25  96%  88%  99% 
23  Oklahoma  24  95%  88%  99% 
24  Kansas  23  96%  93%  99% 
Iowa, Minnesota, Montana,  23  96%  92%  99% 
25  Nebraska, North Dakota, South 
Dakota, Wyoming 
26  New Mexico  24  96%  88%  99% 
27  Colorado  24  96%  93%  99% 
28  Arizona  23  96%  92%  99% 
29  Nevada  25  96%  93%  99% 
30  Oregon, Washington  24  96%  93%  99% 
31  Idaho, Utah  26  96%  92%  99% 
32  California  25  96%  93%  99% 
33  Hawaii  19  96%  93%  99% 
34  Alaska  25  96%  93%  99% 
Source:  OIG analysis of formularies inclusion of drugs commonly used by dual eligibles, 2016. 
 
*PDP. 
**MA-PD. 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)  Page 27  Andrew M. Slavitt 
Table D-2:  MA-PD Formularies Inclusion of Commonly Used Drugs, by MA-PD Region 
Average Rate of 
MA-PD  Number of 
State(s)  Inclusion by  Minimum Rate  Maximum Rate 
Region***   MA-PDs 
Formularies 
1  Maine, New Hampshire  46  96%  95%  99% 
Connecticut, Massachusetts, Rhode  88  97%  92%  99% 
2 
Island, Vermont 
3  New York  205  97%  92%  99% 
4  New Jersey  42  96%  88%  99% 
Delaware, the District of Columbia,  36  97%  95%  100% 
5 
Maryland 
6  Pennsylvania, West Virginia  143  97%  92%  100% 
7  North Carolina, Virginia  109  97%  88%  100% 
8  Georgia, South Carolina  66  97%  94%  100% 
9  Florida  229  97%  90%  99% 
10  Alabama, Tennessee  88  97%  94%  98% 
11  Michigan  60  97%  92%  99% 
12  Ohio  114  97%  92%  100% 
13  Indiana, Kentucky  92  97%  94%  98% 
14  Illinois, Wisconsin  127  97%  91%  100% 
15  Arkansas, Missouri  73  97%  88%  98% 
16  Louisiana, Mississippi  61  97%  94%  97% 
17  Texas  139  97%  94%  99% 
18  Kansas, Oklahoma  53  97%  95%  99% 
Iowa, Minnesota, Montana, Nebraska,  78  97%  91%  99% 
19  North Dakota, South Dakota, 
Wyoming 
20  Colorado, New Mexico  59  97%  94%  100% 
21  Arizona  68  97%  94%  99% 
22  Nevada  29  97%  94%  99% 
23  Idaho, Oregon, Utah, Washington  167  97%  92%  100% 
24  California  281  97%  93%  100% 
25  Hawaii  18  97%  94%  100% 
Source:  OIG analysis of formularies inclusion of drugs commonly used by dual eligibles, 2016. 
***Region 26, which covers Alaska, had no MA-PDs available for 2016. 
 
 
 
Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles:  2016 (OEI-05-16-00090)