Burden on patients: Access to medicines in health insurance exchange plans

Allyson Funk   |     June 23, 2016   |   SHARE THIS

ABC-logo.pngAccess to prescription medicines is critical to help patients manage their chronic conditions and maximize quality of life. Unfortunately, even with insurance coverage, many patients still struggle to get the medicines they need due to high out-of-pocket costs and other plan restrictions. We looked at the burden on patients with health insurance exchange coverage in 2014 and 2015. Now, we’re taking a look at 2016 coverage.

A new analysis by Avalere Health offers data on access to medications for chronic conditions in exchange plans in 2016. For many, as highlighted in earlier research, health insurance exchange plans may cover a medicine, but place it on the highest cost-sharing tier. When the medicine a patient needs – brand or generic – is on a high cost-sharing tier with no alternative on a lower cost-sharing tier, patients are faced with tough choices. This is one reason why more needs to be done to engage and empower patients and stop practices that may discriminate against patients with certain chronic conditions.

Here’s how 2016 health insurance exchange coverage stacks up for patients with these five conditions:

  • HIV/AIDS: There has been an increase in how often HIV medicines are placed on lower cost-sharing tiers in 2016 exchange plans overall, but these plans still place HIV/AIDS medicines on the specialty tier more often than employer-based plans.
  • Oncology: Half of all exchange plans put all cancer medicines in the antiangiogenic agents class on the specialty tier. One-third of the time, cancer medications are placed on the specialty tier – more than twice the frequency of employer plans.
  • Cystic fibrosis: Almost half (48 percent) of exchange plans place all innovative cystic fibrosis medicines on the specialty tier, which usually requires greater cost sharing for patients.
  • Mental health: Many patients face coinsurance of greater than 40 percent for medicines that treat mental health conditions, and these medications are more than twice as likely to be excluded from exchange formularies compared to employer-sponsored plans.
  • Multiple sclerosis (MS): While coverage is improving, more than one-third (36 percent) of marketplace plans still place all innovator brand MS medicines on the specialty tier.                                                                       

Check back next week – we’ll be covering five more conditions. For more, visit AccessBetterCoverage.org.

Allyson Funk

Allyson Funk Ally is a former senior director of public affairs at PhRMA focused on advocacy issues for the biopharmaceutical industry. Her expertise includes Medicare, Medicaid, 340B, health reform and more. Prior to PhRMA, her experience included leading health communications for a large membership organization, supporting public affairs clients and working for the governor of Louisiana.

Topics: Access, Cancer, Cystic Fibrosis, Affordable Care Act, Health Insurance, HIV/AIDS, Burden on Patients, Multiple Sclerosis, Mental Illness, Access Better Coverage, Policy Solutions, Empower Consumers

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