Dive Brief:
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A new study from Avalere indicates 2016 is seeing health insurance plans offered under the Affordable Care Act increasing the accessibility of medications for complex diseases compared to prior years. These conditions include HIV, cancer, and multiple sclerosis (MS).
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Avalere based its findings on silver-level exchange plans and looked at 20 classes of medications.
- The specific difference this year is ACA health plans proved less likely to have placed all drugs in a particular class in their highest cost-sharing tier.
Dive Insight:
The finding indicates a turnaround from 2015 when critics suggested numerous health plans were using "adverse tiering," in which all drugs for certain chronic conditions are placed in the highest cost-sharing tiers, to dissuade those with pre-existing conditions from enrolling. Last November, Avalere reported 30% of 2015 silver exchange plans placed all 10 HIV treatment regimens in their highest tier.
Patient advocates and policymakers had warned such pricing could undermine much of the purpose of the Affordable Care Act by leaving patients with prohibitively high costs, and perhaps force other plans to adopt similar drug formularies to avoid unfairly attracting clusters of sick customers.
Avalere's new study finds for five of the 20 classes of drugs it studied, some plans still had all drugs from a class on their highest tier. However, fewer exchange plans are doing that in 2016 that they did during the previous two years.
Avalere notes CMS has issued guidance discouraging the strategy and that California passed legislation banning it beginning in 2017.
“The trend toward better formularies is good news for consumers,” Caroline Pearson, senior vice president at Avalere, stated. “Plans that place some drugs used to treat a particular condition on a lower tier may improve access to treatments and mean patients pay less out-of-pocket for their care.”