Study Finds Improved Formularies for Specialty Drugs Through ACA Health Exchanges


Study finds fewer exchange health plans are placing specialty drugs on the highest tier.

Health insurance plans through Affordable Care Act (ACA) exchanges are making complex specialty drugs more accessible in 2016, a study by Avalere Health found.

Researchers analyzed silver level exchange plans across 20 classes of medications.

The results showed 5 drug classes, including drugs that treat HIV, cancer, and multiple sclerosis (MS), that some plans placed all drugs for in the highest tier. However, less exchange plans placed these drugs in the highest tier in 2016 than in the previous 2 years.

Previously, cancer medications in the antiangiogenics class were forced into universal placement on the specialty tier, while half of silver plans placed all covered drugs in this class on the specialty tier in 2016.

Furthermore, nearly one-third of silver plans placed all covered MS drugs on the specialty tier, but the rate decreased by 14% from 2015.

The largest decline year-over-year was for molecular target inhibitors at 18%. So far, 2016 has shown a reversal in the significant growth of the tiering structure for the antiangiogenics class, molecular target inhibitors, and MS drugs that occurred between 2014 and 2015.

“The trend toward better formularies is good news for consumers,” said Caroline Pearson, senior vice president at Avalere. “Plans that place some drugs used to treat a particular condition on a lower tier may improve access to treatments and mean patients pay less out-of-pocket for their care.”

CMS has issued guidance that discourages plans from placing all drugs used to treat a condition on the highest tier, without regard to the medication’s cost. However, the federal government has yet to create a tool to help regulators evaluate benefit designs.

“Insurance departments across the country need tools to ensure CMS’s guidance is implemented,” said Kelly Brantley, director at Avalere. “A tool that evaluates formulary tier placement could help ensure patient access.”

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