The lack of transparency about prescription drug coverage on the public health insurance exchanges should serve as a wake-up call to benefit advisers looking to offer a value-add to their clients, one industry expert says.

A report Monday from Avalere Health says in almost half of exchange plans it is difficult or impossible for enrollees to determine what drugs are covered by the plan. Further, 38% of plans had no formulary data available, “presenting significant obstacles to consumers,” the Washington, D.C.-based health care think tank says.

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"Employers are increasingly seeking transparency on prescription drug pricing and they will be turning to benefit advisers for this information,” says Brenda Gagnon, a pharmacy benefit adviser and president and CEO of the health care consulting firm B.M Gagnon Associates.

"The study confirms what agents and brokers have known all along, that important prescription drug information is extremely difficult to come by,” says Ronnell Nolan, president and CEO of the Baton Rouge, La.-based Health Agents for America.

Gagnon agrees it’s no surprise the information is hard to find. She says the difference between how much a member or employer pays a pharmacy benefit manager (PBM) for a prescription drug and what the PBM reimburses the pharmacy for that drug is where most health plans make their money.

Benefit advisers can monitor the price differences and pass that information along to their clients, she says, offering a potential savings on their health care costs.

She predicts many more employers, realizing that lack of prescription drug price transparency is costing them money, will be working with advisers to erect pass-through arrangements in which the PBM is paid a flat administrative fee either per member per month, per employee per month or per claim.

HAFA’s hope, Nolan says, is that the U.S. Centers for Medicare and Medicaid Services will “review the [Avalere Health] study findings, listen to the real-world experiences of agents and brokers that are assisting consumers to understand and utilize their health benefits and require exchange plans to make prescription drug information more transparent."

Avalere Health says Healthcare.gov did offer better drug transparency compared to some state exchanges and the site will further improve drug coverage transparency by requiring plans to submit direct links to formularies in 2015.

For the analysis, Avalere analyzed formulary and provider directory accessibility among plans sold in five states via HealthCare.gov and through 12 state-based exchange websites.

HealthCare.gov and several other state websites — including Colorado, Connecticut, Maryland, Minnesota, Nevada and New York — include a link to formularies and provider directories for each plan.

“Providing understandable and accessible information about the providers and drugs included in exchange plans is essential to helping enrollees make informed purchasing decisions that balance premium against scope of coverage,” says Caroline Pearson, vice president at Avalere Heath.

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