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Higher Share of Marketplace Plans Charging Patients Higher Fees for Certain Drugs, Study Finds

By Melanie Zanona, CQ Roll Call

February 11, 2015 -- More health insurance plans on the exchanges are placing drugs to treat complex diseases at the highest cost-sharing tier in 2015 when compared to the previous year, according to a new analysis from the Avalere Health consulting firm.

“Enrolling in a plan that places all medications for a particular disease on the specialty tier can mean significant out-of-pocket costs for consumers, particularly if they do not qualify for cost sharing reductions,” said Caroline Pearson, vice president at Avalere, in a press release. “Plans that place some drugs in a class on lower tiers may allow consumers to find lower cost alternatives.”

Avalere found that some plans placed all of the drugs within five classes of medication on the specialty drug tier—which could mean higher coinsurance and costs for patients. The medications included those to treat multiple sclerosis, two classes of drugs to treat HIV/AIDS, and two classes of cancer drugs.

The report shows that 51 percent of exchange plans put all multiple sclerosis agents, including generics, in the highest tier in 2015, up from 42 percent in 2014. Meanwhile, 29 percent of plans——nearly double the amount in the previous year—placed protease inhibitors and available generics used for HIV/AIDS patients on the specialty tier, compared to 16 percent in 2014.

Oncology’s antiangiogenics was the only class of drugs to see a slight dip in 2015, but still remains high with 60 percent of plans placing all the medications in the top tier. The study notes that there are no generics for these cancer drugs or two other classes of drugs identified in the report.

Some patient advocacy groups seized on the new information, which they maintain is a trend that started among plans in 2014 and grew this year.

“We believe some insurers are purposefully designing plans in such a way that discourages patients, particularly those with chronic health care conditions, from signing up for them,” said Carl Schmid, deputy executive director of the AIDS Institute. “This is clear discrimination and a violation of the Affordable Care Act.”

Kevin Counihan, the CEO of the federal marketplace, said on a call with reporters that he had not yet seen the Avalere report but intended to read it soon.

The AIDS Institute is urging the federal government to enforce non-discrimination provisions in the 2010 health care overhaul by making medications more affordable to all patients and providing a clear picture of what exchange plans in 2016 will look like for patients.

But Avalere noted that the total cost impact to a patient varies on multiple factors, including subsidies, out-of-pocket limits, and overall plan benefit design.

“Plans continue to innovate on benefit design in the exchange markets,” said Dan Mendelson, CEO of Avalere, in a press release. “These designs are calibrated to optimize enrollment by delivering low and stable premiums—the primary metric that consumers use to select a plan.”

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