Specialty Tiers Hinder Access for ACA Exchange Patients

by Amanda Conschafter, blog editor

Patients who had hoped to attain comprehensive health care coverage through the Affordable Care Act may be discovering yet another roadblock to treatment. Recently released research from Avalere Health shows that the cost-sharing required by some exchange health care plans asks patients battling serious illness to pay substantial out-of-pocket costs for their vital medications. Patients who cannot afford to pay hundreds or thousands of dollars for medication each month face limited access – and difficult decisions about the value of treatment.

High out-of-pocket costs stem largely from the exchanges’ use of specialty tiers, a payment approach explored in depth by an Institute for Patient Access policy brief. Within a structure of four or five tiers, insurers assign less expensive, more common drugs to Tier 1. It carries a relatively affordable co-payment such as $15 or $20. More expensive, advance medications – such as those needed to treat life-threatening diseases – typically belong to the highest, “specialty” tiers. Specialty tiers often require co-insurance, a percentage of the drug’s cost, instead of a flat co-payment. The result is a much greater out-of-pocket cost burden.

Avalere Health’s study reveals that specialty tiers are surprisingly prevalent among exchange plans – despite many patients’ expectation that the Affordable Care Act would, in fact, offer them affordable care. Researchers analyzed cost-sharing for 19 classes of drugs; in seven of the classes considered, one-fifth of Silver plans required co-insurance payments of 40 percent or more. The study also reveals that 60 percent of Silver plans assign approved medical therapies for Crohn’s disease, certain cancers, multiple sclerosis and rheumatoid arthritis to the highest tier – arguably burdening the most vulnerable patients with the most unmanageable medication expenses.

The study’s findings have prompted outcry from several advocacy organizations. Immune Deficiency Foundation President Marcia Boyle noted that, “One of the promises of the [Affordable Care Act] was that an illness wouldn’t force people into bankruptcy. The growing trend of prescription coinsurance will gut that promise unless something is done to stop it.” HealthHIV Executive Director Brian Hudjich echoed Boyle’s concerns, saying, “By placing HIV medications on the top formulary tiers, the plans are restricting access to life-saving treatment, directly countering the intent of meaningful health reform and placing patients at significant risk.”

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