Medicare Coverage of Smoking Cessation Medications Worse Than Medicaid, Private Insurance, Study Says

Medicare coverage of varenicline and combination nicotine replacement therapy (CNRT), the most effective smoking cessation medications, is considerably worse than Medicaid or private insurance coverage, according to a study published in Public Health in Practice.

Based on public health research, reducing out-of-pocket smoking cessation costs promotes more quit attempts and higher quit rates overall. Consequently, the researchers explained that the Affordable Care Act (ACA) required most private insurers to impose no cost sharing for the US Preventive Services Task Force “Grade A” preventive services, which includes all 7 FDA-approved smoking cessation medications.

The ACA also required Medicaid to provide smoking cessation medication coverage, but there are no restrictions on cost sharing. Because Medicaid is managed by state government agencies, policies vary state by state, but most provide smoking cessation medications with a low co-payment of $5 or less.

On the other hand, Medicare Part D does not cover over-the-counter (OTC) products, including smoking cessation products. Similarly, Medicare Part C does not typically cover OTC medications. Although varenicline is covered by both Medicare parts since it is a prescription drug, patients have to pay as much as $469 per month for co-pays.

Despite the coverage disparities, there are little to no data comparing the differences in access to varenicline and CNRT that patients with Medicare, Medicaid, or private insurance face. Because of this, the researchers aimed to “characterize patients’ ability to obtain prescribed varenicline or CNRT across 3 general categories – Medicare, Medicaid, and private.”

The researchers conducted their study strictly using patients from the Duke Smoking Cessation Program to minimize state policy differences, provider prescribing differences, and demographic variability across treatment populations. They created their population using electronic records between May 26, 2016, and July 21, 2021, of smokers 18 years or older with Medicare, Medicaid, or private insurance.

“For each patient, all notes from the Smoking Cessation Program were manually reviewed and systemically coded to denote if the patient faced financial barriers to medication including unaffordable co-pay, unaffordable OTC cost, or necessity of patient assistant programs,” the authors wrote. “A patient was defined as having a ‘financial barrier’ if they were unable to purchase the prescribed medication with insurance coverage or personal funds.”

Also, to evaluate treatment response, the researchers assessed which patients successfully took their medication; only patients who attempted to pick up prescribed medications were considered. They also conducted secondary analyses to discover if exposure to varenicline or CNRT was associated with abstinence.

No smoking

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The study population consisted of 1223 smokers, 607 of whom with Medicare, 457 with private insurance, and 157 with Medicaid. Medicare patients had a mean (SD) age of 63.7 (9.27) years, which was significantly higher than both patients with Medicaid (49.2 [11.18]; P < .001) and private insurance (50.9 (10.89); P < .001).

The researchers found that 88.9% of patients overall, 89.3% of patients with Medicare, 92.3% of privately insured patients, and 84.3% of patients with Medicaid were prescribed varenicline or CNRT. Of those prescribed, 1000 patients (92%) overall picked up their medication; this included 83.2% of patients with Medicare, 90.8% of privately insured patients, and 93.3% of patients with Medicaid.

Additionally, 784 (78.4%) of those who picked up their medications used them for at least 2 weeks; 78.6% of patients with Medicare did so, along with 87.2% of both privately insured and Medicaid patients. The researchers found that the patients who took varenicline or CNRT were more likely to reach abstinence as the abstinence rate for those exposed to the respective medications was 26.3% compared with 16.7% for those taking other treatments. Consequently, those who took the medications achieved a smoking abstinence rate 1.58 times higher than those who could not (P < .001; 95% CI, 1.14-2.17).

From these data, the researchers determined that 45.1% of patients with Medicare had financial barriers to varenicline or CNRT. Additionally, they were 5.08 times more likely than privately insured patients (8.9%) (95% CI, 3.62-7.13; P < .001) and 2.82 times more likely than patients with Medicaid (16.0%) (95% CI, 1.86-4.27; P < .001) to face a financial barrier.

The researchers also acknowledged their study’s limitations, one being that some patients had longer follow-up periods, making assessment dependent upon each patient’s engagement in care. Also, because the study was conducted in North Carolina, the results for patients with Medicaid may not be generalizable since policies vary from state to state.

Consequently, to build upon their findings, the researchers suggested analyzing CMS prescription and cost data as it may better characterize national trends, helping to further evaluate these disparities. Based on their findings alone, they suggested extending ACA requirements to Medicare parts D and C.

“To close this Medicare coverage gap, ACA requirements which apply to private insurers could be instituted for Medicare Part D and C (which are managed by private companies) with explicit coverage for OTC nicotine replacement,” the authors wrote.

Reference

Masclans L, Davis JM. Access to effective smoking cessation medications in patients with Medicare, Medicaid and private insurance. Public Health Pract (Oxf). 2023;6:100427. doi:10.1016/j.puhip.2023.100427