Drug benefits stand as some of the most consequential consumer confusions that can arise in public exchanges, increasing the onus on insurers to improve the design and explanation of formularies.
Among all the actual and perceived Affordable Care Act "horror stories" was one high-profile case involving a Humana individual plan formulary, a cancelled policy and access to cancer medications. In a widely-circulated article, Wall Street Journal editor Stephen Blackwood wrote that his mother, a neuroendocrine cancer patient, "used to have a policy that covered the drug that kept her alive. Now she's on her own."
Blackwood's mother bought the plan in November on the assurance from brokers Sandostatin, a drug she took to treat diarrhea associated with carcinoid tumors, was included in the formulary. In February, however, she was told the drug would not be covered, leaving her exposed to thousands of dollars in monthly costs.
The drug, which does not yet have generics, may or may not be covered for Blackwood, who filed an appeal. But either way the case highlights the potential for consumer problems as they migrate to exchange plans.
Medications that individuals have long been taking, whether for life-threatening diseases like leukemia, chronic diseases like diabetes or more minor conditions like acid reflux, can suddenly be unavailable or available at higher out-of-pocket costs or through generic versions -- all of which can leave new and old members alike frustrated and apt to switch plans at the next chance.
Exchange plan shoppers should have direct access to various plan formularies before buying, with the ability to search and easily compare cost-sharing -- and insurers still have to improve that overall experience.
But many of the cases of confusion during the first wave of open enrollment probably stemmed from a combination of cancelled plans, poor HIX website technology and less-than-due-diligence on the part of shoppers, said SuAnn Stone, business development director at OmedaRx, the pharmacy benefits unit of Cambia Health Solutions, the parent of Regence Blue Cross plans in Oregon, Washington, Idaho and Utah.
"People were surprised last year due to the multiple changes," Stone said. "Plans were changed, and people weren't able to do the research they needed to do to understand these changes."
Some consumers may have had a $20 or $30 co-pay in a previous plan, or one that was updated, and "assumed it would be same." Or the formulary could have changed with some drugs removed or substituted.
Insurers on both public and private exchanges, and in group plans, need to do a better job presenting and explaining their formularies, and that is the general trend. "I hope it gets easier in this earlier enrollment season," Stone said. "It should be similar in concept to what a senior should do to sign up for a Medicare Advantage drug plan," evaluating drug tiers, drug choices and co-pays.
In Cambia's Bridgespan exchange plan in Washington, the online drug formulary lists the one of four tiers corresponding to cost-sharing, coverage details, quantity limits, and whether a prior authorization is involved.
To improve the consumer experience in HIX drug benefits, part of the goal, Stone argues, should be getting consumers to do more thorough research before making a decision on a health plan, especially if they want to keep taking a certain medication.
And if affordability is a main concern, they might also consider changing their medications, Stone suggests.
This can be complicated and perhaps close to impossible for members taking speciality medications. While there are about a dozen immunoglobulin products available to treat primary immune deficiency, for instance, some have sodium-based stabilizers, which could be problematic for patients with heart disease, while others have fructose-based stabilizers that should be avoided by diabetics.
But for less-threatening conditions that are fairly interchangeable, generic drugs are increaingly becoming available, and it's not unreasonable for many consumers to think about changing medications, Stone said.
They could check with their doctor, and say "this plan is most affordable for me, but my medication isn't on it. Is there another drug or generic that's available for me?"
"For many categories, there are other drugs that can be used," said Stone. "In the heartburn class, for instance, there are five to six generic products available ranging from maybe $30 to $100 per month," while heavily-advertised brands that are basically the same drug can cost more than $200 per month.