Insurer Tools to Save Seniors Money on Prescription Drugs Could Put Them at Higher Risk of Stroke


Insurer and pharmacy benefit manager policies used to cut the cost of drugs could be so time consuming that they could put newly diagnosed atrial fibrillation patients at risk of stroke.

Patients diagnosed with atrial fibrillation (AF) are less likely to use non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin within 30 days of diagnosis due to insurer policies and high costs, which could result in adverse health effects, such as stroke, according to a study published in The American Journal of Managed Care.

Warfarin is an anticoagulant long used to treat AF, a major risk factor for stroke, though it does not mix well with all food or medications. Although NOACs were found to be more effective and less burdensome than warfarin, they cost much more.

“Insurers efforts to control health spending increasingly rely on restricting access to high-cost therapies. In the case of NOACs, these policies may be penny wise and pound foolish,” said Geoffrey Joyce, Schaeffer Center senior fellow and associate professor at the USC School of Pharmacy, in a press release.

Studying fee-for-service Medicare beneficiaries, the team examined how these patients were affected by 2 insurance tools that supposedly reduce prescription drug costs.

One policy, known as step therapy, requires patients to take a generic—and often cheaper—medication first. The other policy, prior authorization, requires an insurance professional to approve the therapy before a patient can use it. These policies are intended to decrease unnecessary drug use and waste. In practice, these policies made it difficult for patients to access their medication, even the generic and cheap options, such as warfarin, according to the study.

“We tested the association between coverage restrictions and NOAC use, including initiation and compliance, and whether coverage restrictions were associated with an elevated risk of stroke and bleeding,” said Seth Seabury, senior fellow at the USC Schaeffer Center and associate professor at the USC School of Pharmacy, in a press release.

Part D insurance plans for beneficiaries were divided into two. If a person had access to 1 NOAC without prior authorization or step therapy, they had an unrestricted Part D plan. If NOACs had protocols before being accessible to patients, patients had a restricted Part D plan.

All beneficiaries in the restricted Medicare Part D plan were less likely to use a NOAC, according to the findings. They were also less likely to correctly adhere to the medication instructions. Only 46% of people on restricted plans received a NOAC within 30 days of their AF diagnosis, whereas 55% of unrestricted beneficiaries received their initial prescription.

Researchers also looked at an association between formulary restrictions and clinical outcomes. They discovered that patients on a restricted insurance plan had a higher aggregate risk of death, stroke, transient ischemic attack, or systemic embolism than participants with unrestricted coverage.

The team believes that more lives can be saved with better access to NOACs. For AF patients specifically, anticoagulant therapy is an underused but effective treatment option.

“Limiting access to NOACs through step therapy or prior authorization may exacerbate the current underuse of anticoagulants and increase the risk of stroke among newly diagnosed AF patients,” Joyce explained in a press release.

Joyce concluded that “All pharmacy benefit managers and Medicare Part D plans need to continuously review their formulary policies to make sure that patients have timely access to effective medications.”


Efforts to save money on prescription drugs associated with increased stroke risk for seniors. EurekAlert! Aug 8, 2022. Accessed on Aug 9, 2022.

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