New enrollees in healthcare exchanges to pay higher drug costs

December 20, 2013

The newly enrolled individuals in the healthcare exchanges will be faced with higher out-of-pocket costs for their medications than those who receive insurance through their employers, according to an analysis by Avalere Health of more than 600 health plans in the exchanges.

The newly enrolled individuals in the healthcare exchanges will be faced with higher out-of-pocket costs for their medications than those who receive insurance through their employers, according to an analysis by Avalere Health of more than 600 health plans in the exchanges.

“In the exchange market, many carriers have added additional tiers compared to employer-sponsored plan formularies. Most frequently, we have seen tiers designated for specialty products, which has historically been less common in the commercial employer market,” said Matt Eyles, executive vice president at Avalere Health, on its website.

The majority of consumers (91%) who purchased a health plan from federally-facilitated and state-based exchanges will find that the drug formularies have four or more cost-sharing tiers, with the top-tier medications requiring coinsurance payments.

“Consumers relying on specialty pharmaceuticals should anticipate out-of-pocket costs tied to a percentage of their mediation cost. With many specialty drugs costing several thousand dollars, this could require patients to outlay significant dollars before reaching out-of-pocket maximums,” noted Caroline Pearson, vice president at Avalere Health.

This cost-sharing is consistent with Medicare Part D plans, with 94% having four or more cost-sharing tiers. In employer-sponsored health plans, only 23% have drug formularies with four or more tiers, 59% have three tiers, and 19% have two or fewer tiers, according to Avalere’s analysis.