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Rebecca Farley

Director, Policy & Advocacy, National Council for Behavioral Health

Exchange Plans Raise Costs of Specialty Drugs for 2015

December 4, 2014 | Health Insurance Exchanges | Comments
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A new study from the health care consulting firm Avalere finds that qualified health plans sold on the federal and state marketplaces continue to use formulary tiering as a method for holding down premium costs, forcing consumers to pay more for certain specialty medications.

The study examined federal- and state-based marketplace plans to identify on which formulary tier the plans place specialty drugs such as those used for the treatment of cancer or rheumatoid arthritis. Typically, drugs on lower tiers will require little to no consumer cost-sharing, while drugs placed on higher tiers may require consumers to pay a high coinsurance, often a substantial portion of the drug’s price.

Avalere found that 91 percent of Bronze plans, 80 percent of Silver and Gold plans, and 66 percent of Platinum plans charge coinsurance for specialty drugs. Notably, more than four in ten Silver plans charge coinsurance of greater than 30 percent on specialty drugs. About two-thirds of marketplace consumers enrolled in Silver plans last year.

Plans often rely on formulary tiering and coinsurance requirements to keep premiums low, but this shifts the cost of care onto consumers in need of expensive drugs, such as mental health medications. High levels of coinsurance can make some drugs unaffordable to patients, and results in unpredictable health care costs for those patients.

The findings from the Avalere study indicate that consumers and advocacy groups must be vigilant about monitoring prescription drug access in marketplace plans and must continue to urge the Obama Administration to strengthen regulations that protect consumers’ access to drugs. The National Council is part of a coalition of national groups working to improve the Affordable Care Act’s “essential health benefits” requirement and ensure that health plans do not impose discriminatory requirements on patients’ access to specialty drugs.