Striking a Balance Between Affordability and Generosity

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2014 has accomplished a great deal in terms of patient access, with the establishment of the exchange plans and the exchange market.
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We are experiencing higher than expected enrollment, with 8.1 million individuals to date, and have begun to really understand the available products for patients in need of insurance.

In terms of the plans themselves, we are starting to also recognize the similarities and differences between what exchange plans cover, versus what standard commercial plans cover. We are finding that not only are exchange premiums more affordable and more generous than anticipated, but pharmaceutical coverage, for both self- and physician-administered drugs, are also relatively similar. The real differences between these plan types, however, lie in the cost-sharing and utilization management, which is notoriously higher among exchange plans.

I see two major areas ripe for additional refinement moving forward: 1) improving network adequacy in exchange plans (i.e. ensuring that exchange plans include a wide array of specialists), and 2) increasing exchange plan transparency. Currently, only two states use a searchable tool to determine if one’s provider is covered, and only one state has a similar tool to determine whether a specific drug is covered. In order to improve patient access, these must expand.

View Tanisha’s full patient access interview with the NCCS.

Webinar | A Closer Look at Patient Support On June 6 at 2 PM ET, Avalere experts will explore how potential implications of the Inflation Reduction Act (IRA)’s out-of-pocket cap, in addition to other key regulatory and policy activities shaping benefit design and patient cost-share (e.g., EHB), could impact patient commercial and foundation assistance. Learn More

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