Specialty Drug Tier Grows for Many Exchange Benefit Designs

Certain exchange benefit plans have recently begun to place all specialty medications for complex diseases on the highest drug formulary cost-sharing tier, according to an analysis from Avalere Health.

Certain exchange benefit plans have recently begun to place all specialty medications for complex diseases on the highest drug formulary cost-sharing tier, according to an analysis from Avalere Health.

The report found that plans placed 5 of the 20 drug classes studied on the specialty tier and of the multiple sclerosis agents alone, 50% of plans placed both the branded drugs and generic versions on the highest tier. Additionally, a subset of plans in 10 drug classes listed all single-source branded drugs in a class on the specialty tier and 8 of those drug classes that consisted of single-source branded drugs were more likely to be listed on the highest cost-sharing tier in 2015 than in 2014.

“Enrolling in a plan that places all medications for a particular disease on the specialty tier can mean significant out-of-pocket costs for consumers, particularly if they do not qualify for cost sharing reductions,” Caroline Pearson, vice president of Avalere, said in a statement. “Plans that place some drugs in a class on lower tiers may allow consumers to find lower cost alternatives.”

Taking into account individual based variables, such as subsidies, out-of-pocket-limits and overall plan benefit design, researchers at Avalere Health highlighted that 8 in 10 individuals received a premium tax credit by selecting an exchange plan in 2015, which lowered monthly premium costs by nearly 75%.