Analysis: Patients face more hurdles accessing drugs in exchange plans vs. employer coverage

WASHINGTON — A new analysis from Avalere Health released Monday found that consumers purchasing insurance through exchanges are twice as likely to face utilization management controls on prescription medications compared with people enrolled in employer-sponsored insurance plans. Utilization management controls, including prior authorization and step therapy, are administrative steps that patients and their physicians must complete to demonstrate appropriate use of the drugs. These tools are used by health plans to limit access to specific medications and, in some cases, reduce costs. 

Branded mental health and oncology medications were extremely likely to be subject to step therapy or prior authorization, with more than 70% of covered drugs requiring utilization management in exchange plans. HIV/AIDS drugs had the lowest incidence of utilization management, with more than half of exchange plans providing open access to these medications. 

“This is one more reminder that consumers shopping on the exchange need to look beyond premium costs when picking a plan,” stated Caroline Pearson, VP Avalere Health. “Patients may be better off selecting a plan that includes open access for drugs they use regularly, and they will need to work closely with their physicians to fulfill utilization management requirements where they exist.”

Health plans rely on utilization management tools to encourage use of lower-cost or generic drugs, as well as to ensure that the drugs prescribed are appropriate to a patient’s medical condition. However, those tools also may be a barrier to accessing needed medications, particularly for vulnerable populations like severely mentally ill patients. Utilization management for mental health drugs is more than four times more common for exchanges compared to employer coverage. 

“Insurers offering exchange products are trying balance access and cost to ensure that consumers are getting value,” said Matt Eyles, EVP Avalere Health. “The utilization management tools we profiled are not as widely used in commercial insurance settings, so they need to be closely monitored for their effects on consumers and on the clinicians responsible for their administration.”

Login or Register to post a comment.