Insurance Coverage

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ACCESS TO MEDICINES

Insurance Coverage

Ensuring patients can get the medicines they need to live longer, healthier lives is critical; insurance coverage should provide patients with access to high quality medicines. Whether covered through an employer-sponsored plan, private coverage or a plan from the health insurance exchange marketplace, consumers should be engaged and empowered in their health care decisions. But insurers are increasingly using high deductibles, coinsurance and multiple cost sharing tiers, which result in high cost sharing for some patients. High cost sharing for medications may limit patient access to needed treatments, reduce adherence and lead to poor health outcomes. For more on insurance coverage basics visit Access Better Coverage and for comprehensive reports on coverage and access explore 123s: By the Numbers.

Engaging and Empowering Consumers with Coverage Information

A well-informed consumer is an engaged and empowered patient. We need to make more information on health care out-of-pocket costs and quality available to patients. In addition, vulnerable patients should have the protection of enforceable, commonsense rules that prevent discrimination and remove barriers to access. These steps will improve coverage and access and help make medicines more affordable to patients.

Deductibles for Prescription Drugs Are Becoming More Common

Many consumers are facing higher deductibles and cost sharing – including for services like prescription medicines – that create barriers to accessing needed care. Plans that apply a large deductible to prescriptions can leave patients with high out-of-pocket costs for needed medicines, including those to treat chronic conditions.

A growing body of research continues to raise red flags around the implications of high cost sharing and patients’ ability to access affordable care even if they have insurance. In 2015, 46 percent of commercial plans had deductibles on prescription drugs, double the 23 percent of plans in 2012. And health insurance exchange plans are more likely to require patients to meet a deductible before drug coverage begins.

Insurers Increasingly Place Medicines on the Highest Cost-Sharing Tier

Patients taking medicines placed on higher cost-sharing tiers often face serious and chronic health conditions. Increased use of 4 or more tier formularies means patients face higher cost sharing; this also takes the form of coinsurance, or a percentage of costs, which is less predictable for patients. And despite warnings that requiring high cost sharing for all or most medications to treat a condition may be discriminatory, some health plans continue to engage in this practice.

In the commercial market, plans with 4 or more tiers are becoming more common. Twenty-three percent of workers in 2015 were in plans with 4 or more tiers, up from only three percent in 2004. In health insurance exchange plans, 98 percent of silver plans use 4 or more tiers. Beyond the number of tiers, health insurance exchange plan formularies continue to suggest bias against individuals with certain health conditions by placing all medicines to treat certain conditions, such as cancer or multiple sclerosis, on the highest cost-sharing tier.

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