In 2014, prescription drug benefits varied greatly among the health plans offered through Covered California, the state’s health insurance marketplace, and there were differences in coverage between these plans and California’s most common workplace health plans. In a project supported by CHCF, Avalere Health compared these new individual market plans to one another and to employer-sponsored insurance, the coverage source for most Californians. Researchers examined differences in 2014 pharmacy benefits and in how easy it is for consumers to compare their options.
The report offers insights into how barriers to necessary prescription drugs might further be reduced and how consumer access to drug cost and coverage information could be improved across the individual market. While this report focuses on health plans offered through Covered California, many of the issues it raises reflect the broader individual market and larger trends in formulary design.
Among the report’s key findings:
- For consumers with relatively limited drug needs, plans offered through Covered California provided comprehensive, affordable access to the most commonly used medications.
- Researchers examined drugs used to treat five categories of chronic conditions that rely on medication management—HIV/AIDS, mental health, immunology, asthma/COPD, and diabetes. Formulary coverage, utilization management and tier placement varied by plan and drug class.
- Comprehensive information on drug coverage and out-of-pocket costs was difficult to find, which could hinder consumers trying to make informed purchasing decisions.
- Plans offered through Covered California were more aggressive than selected employer plans in managing prescription drug use through administrative controls, such as prior authorization and step therapy.
The full report is available and a detailed chart pack is available below.