Patients’ Lack of Access to Medicines in Exchanges in Three Charts

Patients’ Lack of Access to Medicines in Exchanges in Three Charts

06.12.14 | By Robert Zirkelbach

All patients should have access to the medicines they need to manage their diseases, enabling them to live fuller, healthier, more productive lives. Unfortunately, recently-released data paints a very troubling picture of patients’ access to medicines in the new health insurance exchanges.  Too often patients are being forced to pay exorbitant out-of-pocket costs for live-saving medicines that not only improve patients’ health and quality of life, but help prevent unnecessary hospitalizations, ER visits, and costly medical procedures.

Below are three charts highlighting the significant barriers that exist for patients with exchange coverage trying to access the medicines they need.  More information about these studies is available at our new ACA webpage.

Many Patients Must Pay Thousands of Dollars Out-of-Pocket Before ANY Drug Coverage Takes Effect

A recent report from Milliman found that patients enrolled in a Silver plan, the most popular coverage option in the exchanges, are nearly four times more likely to face a single combined deductible for medical and pharmacy benefits (46 percent of the time) compared to a typical employer-sponsored plan (12 percent of the time). This is an important distinction, particularly for patients with chronic illnesses, as it means prescription medicines are not covered until patients meet the deductible, often exceeding $2,000. Previous research found that in the lower-cost Bronze plans, deductibles are even higher, averaging more than $4,000.

Even after the Deductible has been Met Patients Face Exorbitant Out-of-Pocket Costs for their Medicines

New data released yesterday from Avalere Health found that most Silver health insurance exchange plans (86 percent) place all medicines for at least one class on the highest cost-sharing tier. The research highlights that many patients with chronic diseases such HIV/AIDS, diabetes, multiple sclerosis, and certain types of cancer are being forced to pay 40 percent or more of the cost of their medicines, including generics.

Patients Eligible for Cost-Sharing Reductions May still Face High Out-of-Pocket Costs for their Medicines

Cost-sharing reductions are one form of assistance available to help lower-income patients afford health care coverage through the health insurance exchanges. But a separate study by Avalere Health found that most health plans are not using the cost-sharing subsidies to lower copays or coinsurance for medicines, especially those on the highest tier. As a result, an individual making $11,000 a year could be required to pay more than $1,000 up front to access needed medicines.  Too often this means patients will be forced to go without their medicines altogether.  

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