Drug Coverage, Costs Under Scrutiny

Feb 01, 2014

Jill Wechsler
Tension between pharmaceutical marketers and pharmacy benefit managers (PBMs) is intensifying. The chaotic rollout of the federal and state-based health insurance exchanges in recent months has made the conflict more apparent. Under pressure to control costs in a rapidly changing and uncertain health care market, insurers are slimming down provider networks in plans offered through the exchanges and by Medicare Advantage. Furthermore, plans and PBMs are cutting formularies, boosting co-pays and coinsurance, extending utilization controls, and reducing pharmacy networks to control prescription drug spending. These actions arouse concerns of health care providers and policy makers (as well as pharma companies) that patients will find out too late that they can't get access to needed care and medicines.

The Affordable Care Act (ACA) requires qualified health plans sold through exchanges to cover at least one product in every drug category and class in the U.S. Pharmacopeia list of approved medicines. But insurers still retain considerable leeway in designing pharmacy benefits and setting copays and coinsurance, even with out-of-pocket maximums for individuals and families. Generally, "gold" and "platinum" plans set higher premiums but have broader formularies and lower individual fees. Pharmacy management tools can vary, such as step therapy and utilization review, as well as use of tiers in formularies that set hefty coinsurance on specialty drugs (those that cost $600 a month or more). Unfortunately, many individuals have found it hard to determine which drugs are covered by a plan until after they sign up, despite efforts by the Centers for Medicare and Medicaid Services (CMS) to make information on provider networks and drug formularies available prior to plan selection.

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