Trends in prescription drug coverage restrictions in Medicare, Medicaid, and commercial insurance plans, 2011-2019
File(s)
Published version
Author(s)
Kyle, Michael Anne
Kakani, Pragya
Burn, Samantha
Maini, Luca
Type
Journal Article
Abstract
Introduction
Access to prescription drugs is an enduring challenge in patient care. Payers often rely on coverage restrictions to balance access and cost.
Methods
We assessed coverage restrictions for a comprehensive set of branded retail drugs without generic competitors from 2011-2019 across the four largest US market segments (Medicare, Medicaid, employer-sponsored, and health insurance exchanges) using CMS and Managed Market Insight and Technology (MMIT) data.
Results
Between 2011-2019, for the nationally representative beneficiary, the share of drugs excluded from formularies increased from 7.5% to 13.4%, the share of drugs subject to administrative restrictions such as prior authorization or step therapy increased from 18.1% to 43.7%, and the share of drugs on non-preferred tiers decreased from 57.8% to 42.2%. The share of drugs with any coverage restriction increased from 69.7 to 79.0%. Health plans and drugs subject to federal coverage mandates saw much larger increases in prior authorization and increases in non-preferred status.
Conclusion
These dynamics suggest that future research should study the tradeoffs between partial and full coverage restrictions for patient utilization, spending, and wellbeing.
Access to prescription drugs is an enduring challenge in patient care. Payers often rely on coverage restrictions to balance access and cost.
Methods
We assessed coverage restrictions for a comprehensive set of branded retail drugs without generic competitors from 2011-2019 across the four largest US market segments (Medicare, Medicaid, employer-sponsored, and health insurance exchanges) using CMS and Managed Market Insight and Technology (MMIT) data.
Results
Between 2011-2019, for the nationally representative beneficiary, the share of drugs excluded from formularies increased from 7.5% to 13.4%, the share of drugs subject to administrative restrictions such as prior authorization or step therapy increased from 18.1% to 43.7%, and the share of drugs on non-preferred tiers decreased from 57.8% to 42.2%. The share of drugs with any coverage restriction increased from 69.7 to 79.0%. Health plans and drugs subject to federal coverage mandates saw much larger increases in prior authorization and increases in non-preferred status.
Conclusion
These dynamics suggest that future research should study the tradeoffs between partial and full coverage restrictions for patient utilization, spending, and wellbeing.
Date Issued
2026-03-01
Date Acceptance
2026-03-05
Citation
Health Affairs Scholar, 2026, 4 (3)
ISSN
2976-5390
Publisher
Oxford University Press
Journal / Book Title
Health Affairs Scholar
Volume
4
Issue
3
Copyright Statement
© The Author(s) 2026. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.
License URL
Identifier
10.1093/haschl/qxag059
Subjects
pharmaceutical policy
benefit design
coverage restrictions
access to care
utilization management
prior authorization
Publication Status
Published
Article Number
qxag059
Date Publish Online
2026-03-10