Increasingly, more insurance plans available on health insurance exchanges are assigning high-cost drugs used to treat complex diseases on lower cost-sharing tiers than in previous years. A study conducted by Avalere Health found that some plans in 2016 are not following the usual trend of offering these types of drugs on the highest cost-sharing tier in their plans’ formularies. Caroline Peterson, senior vice president of Avalere noted that this trend is “good news for consumers” because it “may improve access to treatments and mean patients pay less out-of-pocket for their care.”
Study. The Avalere analysis focused on 20 classes of medications as they are treated on silver-level plans on the exchanges created pursuant to the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The study’s authors explained that typically, “highest priced medicines, which are often relied on by the most chronically ill patients, are often placed on a high formulary tier, indicating high-cost sharing for patients.” Yet, the study revealed that, in 2016, fewer exchange plans are classifying all such drugs on the highest tier.
Specifically, Avalere found that five of the 20 classes, which included drugs used to treat HIV, cancer, and MS were consistently placed on the highest tier and that half of all silver plans placed antiangiogenics, which are cancer treating products, on the high tiers. However, “one-third of silver plans place all covered MS drugs on the specialty tier as well, though this rate is a drop of 14 percentage points from 2015.” For three classes of molecular target inhibitors there was an 18 percentage point decline year-over-year of high-tier classification that “shows a reversal of the sharp increase in this type of tiering structure that occurred between 2014 and 2015.”
Guidance, and lack thereof. While CMS has issued guidance that discourages plans on the health exchanges from placing all the types of drugs used to treat one condition on the same tier, there is no existing tool to evaluate if plans are designed in this way or not. Such a tool would help increase patient’s access to needed drugs, according to Avalere. The authors also noted that a California law that prevents plans from categorizing all drugs for a certain condition on the highest tier will go into effect in 2017.
Companies: Avalere Health
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