Fewer Drugs on Specialty Tiers

Insurance plans offered through the Affordable Care Act are placing fewer drugs on the specialty tier of formularies than they were 2 years prior, according to a new study from Avalere.

In a national survey reviewing 2016 silver-level exchange plans across 20 classes of medications, including a mixture specialty and primary care drugs, Avalere discovered that plans were less likely to place all drug options for complex diseases—like HIV, cancer, and multiple sclerosis—on the highest tier of formularies than they had in 2014 and 2015.

In addition to HIV, cancer, and multiple sclerosis, the researchers noted that there were 2 other classes, for which some plans place all drugs in the class on the highest tier. Half of all silver-level plans placed every drug from the antiangiogenics on the specialty tier in 2016. Nearly one-third of these plans placed all covered multiple sclerosis drugs on the specialty tier as well.

The sharpest decline was for molecular target inhibitors. For these 3 classes, 2016 shows a reversal of the sharp increase in this type of tiering structure that occurred between 2014 and 2015.

The advantage to dispersing drugs throughout different tiers of a formulary could mean more access to drugs with less out-of-pocket costs to patients.

According to the report, while CMS has issued guidance discouraging plans from placing all drugs used to treat a condition on the highest tier without regard to the cost of the medication, the federal government has yet to provide a tool for regulators to 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.”