Health insurers can expect an increasing number of consumer education challenges around prescription drug management, as utilization controls are more prevalent in public exchange plans than in typical group insurance.
According to a new analysis by Avalere Health, new HIX plans are about twice as likely to include prescription drug utilization controls as employer-sponsored plans.
Most insurers post their formularies for different health plan products online, and public exchanges link to carriers' formulary documents from the shopping browser. But for some consumers, especially those with chronic conditions who need maintenance drugs, health plan shopping may require a bit more research.
"This is one more reminder that consumers shopping on the exchange need to look beyond premium costs when picking a plan," Caroline Pearson, Avalere Health vice president and one of the study leaders, said in a media release.
Pearson found that branded mental health and oncology drugs are "extremely likely" to require step therapy or prior authorization in exchange plans, with more than 70 percent of covered drugs coming with some type of utilization management.
Pearson and her colleagues analyzed 84 formularies from bronze- and silver-level plans in the 15 largest states, along with a sample of formularies from the largest federal employee health plan, a publicly-traded, self-insured plan, a self-insured employer plan, a national plan sponsored by a large employer, and a national plan sponsored by a mid-size employer.
About 50 percent of those exchange plans require some form of utilization management for mental health medications, compared to just 11 percent of employer plans, and 43 percent of exchange plans include controls on cancer drugs, compared to 30 percent of employer plans.
HIV/AIDS drugs, meanwhile, were the least likely to come with utilization controls, with only 21 percent of exchange plans and 6 percent of group plans including them.
The extent of pharmaceutical benefits management in exchange plans in some ways represents a new frontier in insurance, given the variation allowed for compliance with the classes of drugs required under essential health benefit regulations and the increasing focus on cost and quality control.
"The utilization management tools we profiled are not as widely used in commercial insurance settings," said Matt Eyles, Avalere executive vice president and co-researchers, "so they need to be closely monitored for their effects on consumers and on the clinicians responsible for their administration."
This new frontier is also drawing more scrutiny from federal regulators, who are considering amending formulary exception standards to expedite access to drugs that aren't covered in "exigent" circumstances.