Exchange-Based Plans Contain Administrative Hurdles for Rx Drugs
People who have health coverage through the Affordable Care Act's insurance exchanges are twice as likely to face mandatory administrative screenings for certain prescription drugs as people who have employer-sponsored coverage, according to a new Avalere Health analysis, Modern Healthcare reports (Tahir, Modern Healthcare, 3/24).
According to The Hill's "Healthwatch," the requirement is an obscure facet of policies in the exchanges known as "utilization management controls." Such controls permit insurers to limit access to certain prescription medications -- either through requiring patients to try cheaper medications first or only providing coverage on a case-by-case basis -- as strategies to control costs and prevent prescription drug misuse.
Some consumer advocates are opposed to utilization controls, suggesting that they can create tedious, or even dangerous, obstacles to care (Viebeck, "Healthwatch," The Hill, 3/24).
For the analysis, researchers looked at prescription drugs in three of 21 common drug classes -- HIV/AIDS, mental health and oncology -- and formularies from bronze- and silver-rated exchange plans in 15 of the largest states. They compared the utilization controls in those exchange plans with controls in a sample of employer-sponsored plans.
The analysis found that 60% of HIV/AIDS drugs were available without utilization controls in exchange-based plans, but that number "still paled in comparison" with employer-sponsored plans, Modern Healthcare reports (Modern Healthcare, 3/24). According to the report, 84% of employer-sponsored plans had controls for HIV/AIDS drugs (Avalere report, 3/24).
Researchers also found that:
- 50% of mental health drugs were available without utilization controls in employer-sponsored plans, compared with 15% in exchange-based plans; and
- 27% of oncology drugs were available without controls in employer-sponsored plans, compared with 16% in exchange-based plans.
In addition, the study noted:
- About 40% of insulin drugs were available without utilization controls in exchange-based plans; and
- Only 5% of multiple sclerosis drugs were available without controls in exchange-based plans (Modern Healthcare, 3/24).