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Avalere Analysis: Cost-Sharing for Specialty Medicines

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In a June 2014 analysis, Avalere analyzed 123 silver exchange plan formularies to evaluate tier placement.

The analysis looked at all brand and generic drugs within 19 drug classes * to determine the potential patient cost sharing burden for these medicines. The data show a substantial number of plans requiring high cost sharing for all medicines in several classes.

    In seven classes, more than 20 percent of the plans require coinsurance of 40 percent or more for all medicines in the class.
    Over 60 percent of the plans place all covered medicines in the class for treating multiple sclerosis on the formulary tier with the highest cost sharing.
    Similarly, over 60 percent of the plans place all covered medicines in certain classes for treating cancer on the formulary tier with the highest cost sharing.
    Almost all plans (86 percent) place all medicines in at least one class on the highest cost-sharing tier.

* Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors; Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors; Anti-HIV agents, protease inhibitors; Anti-HIV agents, other; Serotonin/ Norepinephrine reuptake inhibitors; Antidepressants, other; Antipsychotics, 2nd generation/ atypical; Bipolar Agents-Other; Metabolic Bone Disease Agents; Alkylating agents; Molecular target inhibitors; Antiangiogenic agents; Emetogenic Therapy Adjuncts; Antidiabetic agents; Insulins; Immune suppressants; Multiple Sclerosis Agents; Bronchodilators, Sympathomimetic; and Anti-inflammatories, Inhaled Corticosteroids.

This analysis was funded by PhRMA. Avalere maintained editorial control over the content of the analysis.



Avalere analyzed 123 formularies from plans expected to capture significant Exchange enrollment, representing most major issuers.

The analysis includes formularies from plans offered in a zip code in the largest city(s) in each state, including low-cost silver and bronze plan options, low-cost strategic players (e.g., Blues, Medicaid managed care plans), and additional formularies in states with a high number of silver plan options and very high enrollment. Avalere did not include silver plan variations available to consumers with income between 100 percent and 250 percent of the Federal Poverty Level (FPL) in their analysis.

View Avalere’s full report attached.

For more information on Exchange plans, contact Caroline Pearson at

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