In their own words: Insured Americans struggle to navigate complex coverage

A survey of more than 5,000 Americans conducted with Ipsos found that nearly 40% of insured Americans struggle to understand what their health insurance covers.

The new data come from the third installment of the Patient Experience Survey and reveal how insurers and middlemen like pharmacy benefit managers (PBMs) impose barriers and cost sharing practices that stand between patients and their medicines.

Here are three key findings, along with examples from patients in their own words, from the latest PES report.

1. Patients are concerned about insurer- and PBM-imposed barriers, such as formulary exclusions, prior authorization and other practices.

Nearly half (47%) of insured Americans taking prescription medicine are concerned that a medicine their doctor recommended or prescribed wouldn’t be covered by their insurer (i.e., excluded from the formulary). Additionally, 42% are concerned that they would have to wait for their insurer to provide prior authorization for a medicine their doctor prescribed.

2. Health insurance coverage is confusing for many insured Americans.

Thirty-nine percent of insured Americans say they do not understand what their health insurance covers, and 35% say they have trouble navigating their insurance coverage. Difficulty navigating health insurance rings especially true for those who say they are in poor health (42%).

3. Navigating, understanding and anticipating health insurance coverage is a challenge.

One in five (22%) insured Americans say they have trouble navigating, understanding and anticipating their health insurance. Those with high deductible health plans (27%) and those who switched their health insurance plans within the past year (28%) are particularly affected.

To address these challenges, insured Americans favor policy solutions that improve their ability to navigate and access their care by seeking to remove barriers imposed by insurers and middlemen such as PBMs. Such solutions could lower out-of-pocket costs and simplify the health coverage process for insured Americans. To learn more about challenges Americans face as they navigate the health system and solutions that seek to alleviate these challenges, visit PhRMA.org/Middlemen.

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PhRMA’s Patient Experience Survey (PES) is a research initiative to explore the challenges Americans face as they navigate the health care system. The poll was conducted among 5,103 American adults (age 18 or older), including 4,720 with insurance, from May 23 – June 1, 2022, using Ipsos’ probability-based KnowledgePanel®, and it is representative of the American adult population. The margin of sampling error is plus or minus 1.5 percentage points at the 95% confidence level, for results based on the entire sample of adults. The latest PES also features qualitative data from hours of in-depth interviews.