Summary: Extending insurance coverage to all, even those with serious or pre-existing conditions, was one of the promises of the Affordable Care Act. And yet conditions including high coinsurance and high co-pays have put treatment out of reach for insured people. Here’s a new analysis from Avalere Health saying that some insurance plans “place all drugs used to treat complex diseases – such as HIV, cancer, and multiple sclerosis – on the highest drug formulary cost-sharing tier.” Click here to read more from the report.



“’Plans continue to innovate on benefit design in the exchange markets,’ said Dan Mendelson, CEO of Avalere.  ‘These designs are calibrated to optimize enrollment by delivering low and stable premiums – the primary metric that consumers use to select a plan.’

“Specifically, in five of the 20 classes of drugs analyzed, plans placed all drugs in a class on the specialty tier. Specifically, in the Protease Inhibitor and Multiple Sclerosis Agents classes, 29 and 51 percent of plans respectively place all drugs, including available generics, on the highest tier. There are no generics in the other three classes of drugs listed below.

“Moreover, a subset of plans in each of 10 drug classes placed all single-source branded drugs in a class on a specialty tier. Specifically, in 8 of the 10 classes, 2015 exchange plans were more likely than 2014 plans to assign all single-source branded drugs to the highest cost sharing tier. A single-source branded medication is a brand name drug without a generic equivalent. The practice was most common for some cancer drugs and drugs used to treat multiple sclerosis. Roughly 30 percent of plans also place all single-source drugs for HIV/AIDS on the specialty tier.” Caroline Pearson, vice president at Avalere, via Avalere Health : Avalere Analysis: Exchange Benefit Designs Increasingly Place All Medications for Some Conditions on Specialty Drug Tier.

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...