Access to Rx drugs challenged by exchanges

Access to prescription drugs is more challenging for consumers buying insurance through the exchanges than those covered by employer-sponsored insurance plans, an analysis by Avalere Health finds.

Administrative hurdles, dubbed utilization management controls, are more likely to be used by plans in the exchanges as an attempt to limit access to certain drugs or encourage the use of lower cost generic drugs.

The controls, which include requiring prior authorization or the use of step therapy, are also used by plans to ensure the drugs prescribed are appropriate to a patient’s medical condition.

Brand-name mental health and oncology medications were extremely likely to be subject to such controls, according to the study. More than 70% of covered brand-name mental health and oncology drugs required prior authorization or the use of step therapy to justify a drug’s need.

Utilization management for mental health drugs is more than four times more common for exchanges compared with employer coverage, Avalere says.

“Insurers offering exchange products are trying to balance access and cost to ensure that consumers are getting value,” says Matt Eyles, executive vice president at Avalere.

However, the tools can also be a barrier to accessing needed medications, particularly for vulnerable populations like severely mentally ill patients, and should be “closely monitored for their effects on consumers and on the clinicians responsible for their administration,” Eyles adds.

Monitoring usage

A separate Employee Benefit Research Institute study also found moving employees to a consumer-directed health plan could deter patients with chronic conditions from taking their medicines.

Using data from a large employer that replaced its traditional managed-care health insurance with an HSA, EBRI found the move to the HSA-eligible plan reduced the number of prescriptions filled when individuals discontinued use of brand-name drugs without substituting generic alternatives.

“Although lower prescription drug use can save pharmacy costs for plan sponsors, it could also result in even higher downstream medical costs if people stop taking maintenance drugs for chronic diseases,” Paul Fronstin, director of EBRI’s Health Education and Research Program says.

He said CDHP plan sponsors may want to have maintenance medications deemed as preventive and exempt them from the deductible.