Drug Access Concerns for Patients With Chronic Diseases in Covered California

An analysis of health plans offered through Covered California found some consumers with chronic diseases or those who rely on specialty drugs may have faced access and affordability challenges in 2014.

The report, written by Avalere Health and supported by the California HealthCare Foundation, analyzed drug coverage for the 100 most commonly prescribed drugs in the US commercial market and focused on 11 drug classes used to treat 5 common chronic conditions: HIV/AIDS, mental health, diabetes, autoimmune disorders, and asthma/chronic obstructive pulmonary disease.

The researchers discovered that while consumers with limited drug needs had comprehensive, affordable access to the most commonly used medications there was wide variation in the breadth of formularies among the different plans on Covered California. They found that the number of atypical antipsychotics available on formularies ranged from a low of just 5 listed drugs to a high of 11 products. For antidiabetics the range spanned from a low of 9 products to 44.

Analyzing plan tiers, the report found that products used to treat complex chronic conditions were disproportionately placed on the specialty tier in Covered California plans, which discourages consumers from using these drugs because of the high out-of-pocket costs.

“Since specialty drugs can cost several hundred to several thousand dollars per month, consumers who take these medications may experience high out-of-pocket costs until they reach the annual out-of-pocket cap, which was $6350 in 2014,” the authors wrote.

However, the report revealed that one plan had listed all of its HIV/AIDS drugs on the specialty tier, including generics and brands. This practice is not limited to Covered California as a paper in the New England Journal of Medicine found.

Another point of concern was the lack of comprehensive information on drug coverage and out-of-pocket costs. Even the researchers had difficulty finding comprehensive, easily understood information on drug cost and coverage information by health plan.

“This lack of access could be a barrier to consumers who wish to make informed purchase decisions,” the authors wrote.

With some chronically ill patients continuing to face access and affordability challenges in the individual market, Avalere presented policy changes to improve transparency:

• Implement new market-wide reforms, such as standardized, easy-to-understand cost information in the standard formulary template for reporting and displaying formulary information.
• Improve consumers’ ability to comparison shop Covered California plans based on medication needs. Nevada was the only exchange in 2014 that offered a drug lookup tool to help consumers choose plans based on medication coverage.
• Strengthen the transparency of the essential health benefit regulatory standards regarding prescription drugs.
• Better inform California consumers about the exceptions process and other relevant consumer protections through an aggressive consumer education effort.