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Avalere Analysis: Consumers Face More Hurdles to Accessing Drugs in Exchange Plans Compared to Employer Coverage

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A new analysis from Avalere Health finds that consumers purchasing insurance through exchanges are twice as likely to face utilization management controls on prescription medications compared to people enrolled in employer-sponsored insurance plans.
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Utilization management controls, including prior authorization and step therapy, 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, in some cases, reduce costs.

Branded mental health and oncology medications were extremely likely to be subject to step therapy or prior authorization, with more than 70 percent of covered drugs (excluding not listed) requiring utilization management in exchange plans. HIV/AIDS drugs had the lowest incidence of utilization management, with more than half of exchange plans providing open access to these medications.

“This is one more reminder that consumers shopping on the exchange need to look beyond premium costs when picking a plan,” said Caroline Pearson vice president at Avalere Health. “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.”

Health plans rely on utilization management tools to encourage use of lower cost or generic drugs, as well as to ensure that the drugs prescribed are appropriate to a patient’s medical condition. However, those tools may also be a barrier to accessing needed medications, particularly for vulnerable populations like severely mentally ill patients. Utilization management for mental health drugs is over four times more common for exchanges compared to employer coverage.

“Insurers offering exchange products are trying balance access and cost to ensure that consumers are getting value,” said Matt Eyles, executive vice president at Avalere. “The utilization management tools we profiled are not as widely used in commercial insurance settings, so they need to be closely monitored for their effects on consumers and on the clinicians responsible for their administration.”


Avalere PlanscapeTM evaluated 84 formularies from bronze- and silver-level plans in 15 largest states. Plans included in this analysis represent plans from over 90% of plan sponsors offering exchange plans in the largest city in each of these states, including: 5 national carriers, 14 regional carriers, 2 national Medicaid MCOs, and 5 local Medicaid MCOs-several of these carriers participate across multiple states in the sample. Avalere’s analyzed 2014, exchange-specific formularies publicly available at the time of this analysis (November 2013). Avalere captured all coverage, tiering, and utilization management data available in public documents.

Analysis includes single-source branded drugs across 84 plans. Products analyzed generally encompass the most commonly used, branded medications within a class. To develop the list of drugs per class, Avalere consulted the United States Pharmacopeia (USP) Medicare Model Guidelines v5.0 to obtain a listing of the USP Category, USP Class, and Example Drugs. Avalere reviewed 21 drug classes as part of this analysis. Mental health drugs include the following USP classes: Serotonin/ Norepinephrine Reuptake Inhibitors, 2nd generation/Atypical Antipsychotics, Bipolar Agents, and Antidepressants-other. Cancer drugs include: Emtogenic Therapy Adjuncts, Metabolic Bone Disease Agents, Alyklating Agents, Antiangiogenics, Molecular Target Inhibitors, and Selective Estrogen Receptor Modifying Agents. HIV/AIDS drugs include: Non-Nucleoside Reverse Transcriptase Inhibitors, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors, Protease Inhibitors, and HIV-Other (includes Enfuvirtide, Maraviroc, and Raltegravir).

Employer-sponsored insurance (ESI) data sample comes from formularies utilized by the five following plans: Largest federal employee health benefits plan (FEHBP); large publicly-traded, self-insured employer plan; large, self-insured employer plan; national carrier plan sponsored by a large employer; and national carrier plan sponsored by a mid-size employer.

For more information on drug access in Exchanges, contact Caroline Pearson at

View the official Avalere Health press release attached.

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