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Becky Briesacher, PhD; Sachin Kamal-Bahl, PhD; Marc Hochberg, MD, MPH; Denise Orwig, PhD; Kristijan H. Kahler, RPh, MSc

Arch Intern Med. 2004;164:1679-1684.

Background  Previous studies of 3-tier formularies are rare, although the evidence suggests that their cost-sharing structure reduces overall drug spending. However, it is unclear how incentive-based formularies affect the selection of medications with safety advantages, or restrict the access that high-risk populations have to recommended therapies in the higher tiers. This study was designed to determine whether 3-tier formularies influence the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in a population of patients with arthritis.

Methods  This retrospective study used the 2000 MarketScan Research Database, which contains person-level claims data for employer-sponsored health plans. The sample for this study consisted of 20 868 individuals treated for osteoarthritis or rheumatoid arthritis and using NSAIDs while enrolled in tiered drug plans (n = 32). The likelihood of any use of cyclo-oxygenase (COX-2)–selective inhibitors was determined as a function of tiered drug plan coverage, adjusting for other person-level and plan-level covariates.

Results  Use of COX-2–selective inhibitors decreased (63.0% vs 53.6% vs 41.6%, respectively) and use of generic NSAIDs increased (37.7% vs 40.7% vs 55.7%, respectively) as formularies incorporated 1, 2, and 3 tiers. Enrollees in 3-tier plans with arthritis and serious gastrointestinal comorbidities (odds ratio, 0.51; 95% confidence interval, 0.40-0.66) were significantly less likely to use COX-2–selective inhibitors compared with patients in 1-tier plans.

Conclusions  Three-tier formularies appear to reduce the use of COX-2–selective inhibitors among all patients with arthritis, even those at risk of experiencing gastrointestinal complications from using nonselective NSAIDs. These findings are among the first to suggest that tiered-copayment drug plans may be influencing the selection of medications beyond generic and branded products.

From the Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester (Dr Briesacher); Schools of Pharmacy (Dr Kamal-Bahl) and Medicine (Drs Hochberg and Orwig), University of Maryland, Baltimore; and Novartis Pharmaceuticals Corp, East Hanover, NJ (Mr Kahler). Dr Hochberg is a consultant to Astra-Zeneca, Merck & Co, Inc, Novartis Pharmaceuticals Corp, and TAP (Takeda Abbott Pharmaceuticals).

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