Access to Combination Therapies May Be Limited with Exchange Coverage

Would you rather take three different pills a day, following specific instructions for each, making sure you don’t forget one or just one pill a day that has the same effect?

As drug development advances, so have efforts to simplify medication delivery for patients in the form of combination therapies. These medicines contain two or more pharmaceutical ingredients in one single dose to treat a specific disease. 

Patients living with chronic conditions—such as HIV and diabetes—rely on combination therapies because they reduce the number of medications or dosages needed. This in turn helps support medication adherence and improve clinical efficacy—all good news for patients and their physicians.

Despite the value these combination therapies provide to patients, access may be limited in health care exchange plans. The current Essential Health Benefit (EHB) rules dictating which medicines are covered by plans create disincentives to coverage of combination medicines if the individual component medicines are covered or are less expensive when purchased separately.

In silver plans, for example, diabetes single-ingredient therapies are covered 70 percent of the time, while combination therapies are covered only 50 percent of the time. Similarly, HIV single-ingredient therapies are covered 92 percent of the time, compared to 82 percent for exchange plans.

Without an update to ways the government determines whether a plan is meeting EHB requirements, patients are missing out on the benefits of combination therapies to treat chronic diseases.

To learn more about health coverage and access to prescription medicines, visit PhRMA’s new resource, AccessBetterCoverage.org and check out our fact sheet on combination therapies.