Access to guideline-recommended supportive oncology medications in Medicare Part D.

Abstract

328 Background: Supportive care medications are central to oncologic outcomes, yet unlike antineoplastic agents protected under Medicare Part D's six protected-class rules, supportive care agents remain subject to plan-level formulary and utilization management policies without equivalent federal protection. Thus, the national plan-level access to National Comprehensive Cancer Network (NCCN)-recommended supportive oncology drugs remains undercharacterized. Methods: We conducted a cross-sectional analysis of 2025 CMS Part D Public Use Files. Twenty-three supportive agents recommended in NCCN guidelines for Adult Cancer Pain and Antiemesis were grouped as short-acting opioids (n=5), long-acting opioids (n=12), non-opioid analgesics (n=3), and oral 5-HT₃ receptor antagonist antiemetics (n=3). We estimated formulary coverage, prior authorization (PA) rates, and mean monthly retail cost across 2,862 Medicare plans (364 standalone and 2,498 Medicare Advantage Part D plans). Results: Overall, extended-release (ER) analgesics and branded opioids carried the highest monthly costs (range, $122–$1,335), contrasting sharply with non-opioid analgesics and oral 5-HT₃ receptor antagonist antiemetics ($6–$50). Formulary coverage ranged widely (0.3%–100.0%) across agents, with concentrated exclusions focusing on long-acting opioids; 8 of 12 agents were covered by fewer than 20% of plans, while the remaining 4 agents (buprenorphine patch, fentanyl patch, and methadone liquid and oral tablets) with broader formulary coverage (>70%) had PA required by 29.8%–48.8% of covering plans. Access to short-acting opioids was less restricted, with minimal PA (<1%) overall. However, despite nearly universal coverage for oxycodone-containing immediate-release (IR) formulations and hydromorphone IR, oxymorphone IR and tapentadol IR were covered by fewer than 5% of plans. In both opioid categories, tapentadol formulations appeared the least accessible (IR: 0.3%; ER: 1.2%) and most costly (IR: $1,335/month; ER: $775/month). Among non-opioid analgesics, although pregabalin ER was covered by 16% of plans, duloxetine and pregabalin IR achieved universal coverage with no and 15% of plans requiring PA. For oral 5-HT₃ receptor antagonist antiemetics, coverage was near-universal but PA was a dominant barrier, required for all three agents by 72.0%–89.4% of covering plans. Conclusions: In a national sample of Medicare Part D plans, NCCN-recommended supportive oncology medications face substantial and variable restrictions across coverage, PA, and cost, potentially translating into differential quality of care in oncology practice. These findings highlight a clinically concerning policy asymmetry in contrast to the near-universal access afforded to antineoplastic agents, and support extending protected-class principles to guideline-recommended supportive care medications.