Among the 100 most commonly prescribed medications, exchange plans in the market covered 94 percent of the generic and 82 percent of the brand name drugs. Exchange plans covered the same number of top generic drugs as employer plans studied and only slightly fewer brand name drugs.
“For consumers with relatively limited prescription drug needs, exchange plans provide broad and affordable coverage for common drugs, including drugs used to treat high blood pressure, high cholesterol, and acid reflux,” said Caroline Pearson, senior vice president at Avalere. “Since many exchange enrollees were previously uninsured, this coverage represents a major improvement in medication access and reduction in out-of-pocket costs.”
The report also examines formulary coverage, including utilization management and tier placement, for drugs used to treat chronic diseases—HIV/AIDS, mental health, immunology, asthma/COPD, and diabetes. Findings varied by plan and drug class, with ease of access and affordability more challenging for some medications used to treat complex chronic conditions. For more information, view the complete report and the detailed chart pack.
Given variations in drug coverage across participating plans, one major theme throughout the report is the importance of standardized, easy-to-use information to help exchange enrollees select the plan that is best for them. Covered California has already made several important strides to improve transparency in the market, including requiring standard formulary templates and implementing direct web links to formulary documents. State and federal policy makers can go further by:
- Fully implementing these formulary transparency rules, monitoring plan compliance, and considering consumer-friendly enhancements to the rules;
- Improving consumers’ ability to shop based on drug needs by building an online formulary search tool that allows consumers to compare plans based on drug coverage and restrictions;
- Strengthening the transparency of essential health benefit regulatory standards regarding prescription drugs; and
- Better informing consumers about the exceptions process and other relevant consumer protections.
“Transparency is critical to meaningful choice,” said Dan Mendelson, founder and CEO at Avalere. “A consumer should be able to easily understand how any given health plan on the exchange will deliver care – including network access, pharmaceutical availability and estimated cost burden.”