Will insurer cost-sharing limit consumer access to drugs?

The pharmaceutical industry is concerned that cost-sharing within most health insurance exchange plans could limit consumers' access to necessary medications, says a new report from the Breakaway Health prepared for the Pharmaceutical Research and Manufacturers of America.

The worry comes from the fact that most employer-sponsored plans require consumers to pay 22 percent of prescription costs, but similar exchange plans require consumers pay more than twice that amount, reported Kaiser Health News.

For example, specialty drug copays average $80 for employer-sponsored plans, yet consumers will pay $159 for silver plans and $157 for bronze plans for the same medications.

Exchange plans' higher cost-sharing requirements are cause for concern "because you're disincentivizing patients, particularly patients with chronic diseases, to continue to manage their chronic disease in exchange for ... a low premium," PhRMA CEO John Castellani told KHN. "Yet their out-of-pocket expenses are potentially so high that we have to be concerned about whether or not people will be able to afford to continue to get their medicines."

An analysis last month from Avalere Health shows exchange plans categorize certain pricey prescription drugs into specialty tiers, causing consumers to face utilization management controls, including step therapy and prior authorization, FierceHealthPayer previously reported.

Insurers say the problem is that drugs are too expensive. "Research shows that drug prices continue to soar and are one of the leading drivers of healthcare cost increases," Clare Krusing, a spokeswoman for America's Health Insurance Plans, told KHN. "Any discussion of prescription drug coverage must also include a focus on the direct link between rising prescription drug prices and consumer cost-sharing."

To learn more:
- read the Kaiser Health News article