Plans place drugs to treat HIV, MS on highest cost-sharing tier

When it comes to specialty drugs--namely, prescriptions to treat diseases such as HIV, cancer and multiple sclerosis--certain exchange plans place these costly drugs on the highest drug tier, according to a new analysis from Avalere Health.

"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," Caroline Pearson, vice president at Avalere, said in the report. "Plans that place some drugs in a class on lower tiers may allow consumers to find lower cost alternatives."

Avalere analyzed 20 classes of drugs. In five of those classes, plans placed all drugs on the highest tier. In 2015, 30 percent of plans place both speciality drugs and generics for treating HIV on the highest tier. In 2014, 20 percent of plans did so. Similarly, for multiple sclerosis drugs, 51 percent of plans place all drugs on the highest tier. In 2014, 42 percent of plans did so.

Other key findings include:

  • Out of the 20 classes, Avalere found that a subset of 10 classes placed all drugs--both speciality and generics--on the highest tier.
  • Eight of the 10 classes analyzed were found to have plans that placed single-source branded drugs, which are brand-name drugs without a generic equivalent, on the highest tier. This happened more in 2015 than in 2014.
  • Seven of the 10 subset classes have at least one less-costly generic drug.

Avalere mentioned that how much a customer pays depends on subsidies, out-of-pocket fees and a plan's benefit design structure. Research from Express Scripts shows that consumers who enrolled in exchange plans are 59 percent more likely to use specialty drugs that sonsumers on employer-based plans, FierceHealthPayer previously reported. 

The Avalere report comes at a time when insurers are under harsh scrutiny for supposedly discriminating against costly, sick patients. Some insurers have been accused of using benefit design to discourage sicker consumers from choosing their plans--meaning that insurers design their drug formularies to place all HIV drugs in the highest cost-sharing tier, forcing enrollees with HIV to pay more, regardless of which drug they take.

For more:
- here's the report