Patients who think they have done well finding a relatively low premium in an exchange plan under the Patient Protection and Affordable Care Act may be in for a rude awakening: limited access, and hefty costs, to the important drug coverage they need.
That's the analysis from Avalere Health, which concluded that consumers purchasing insurance through the exchanges are twice as likely to face utilization management controls on prescription medications compared to people with employer-sponsored coverage.
Utilization management controls are administrative steps that patients and their physicians must complete to demonstrate appropriate use of the drugs. These tools are used by health plans to limit access to specific medications and reduce costs.
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Patients who use brand-name cancer or mental health drugs are more likely to encounter this problem under PPACA, Avalere said.
For example, utilization management for mental health drugs is over four times more common for exchanges compared to employer coverage, its analysis found, with 51 percent of brand-name mental health meds having special controls on the exchanges, compared with only 11 percent on the employer-based market.
There were not as many hurdles for HIV drugs on the exchanges, though it was still better for those with employer-sponsored coverage.
"This is one more reminder that consumers shopping on the exchange need to look beyond premium costs when picking a plan," Avalere Health Vice President Caroline Pearson said in a statement. "Patients may be better off selecting a plan that includes open access for drugs they use regularly, and they will need to work closely with their physicians to fulfill utilization management requirements where they exist."
Avalare researchers evaluated 84 formularies from bronze- and silver-level plans in 15 of the largest states.
Last month, HealthPocket research found that copayments and co-insurance fees for drugs increased an average of 34 percent under PPACA, with enrollees who use brand-name drugs and specialty drugs getting hit much harder by rising costs.
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