It May Be Harder to Get Your Meds in the Exchange Plans

On the exchange plans, branded mental health and oncology medications are extremely likely to be subject to step therapy or prior authorization. In fact, more than 70% of covered drugs require utilization management in exchange plans. HIV/AIDS drugs have the lowest incidence of utilization management, with more than half of exchange plans providing open access to these medications, according to a report by Avalere Health. Caroline Pearson vice president at Avalere says that consumers shopping on the exchange need to look beyond premiums. Patients may be better off with a plan that provides open access to drugs they use regularly. They will need to work closely with their physicians to fulfill utilization management requirements where they exist, she added.

Health plans rely on utilization management to encourage patients to choose lower cost drugs and use the drugs that are most appropriate to their medical condition. However, these tools may block access to needed medications, particularly for vulnerable populations like severely mentally ill patients. Utilization management for mental health drugs is more than four times more common for exchanges compared to employer coverage. Matt Eyles, executive vice president at Avalere said, “The utilization management tools we profiled are not as widely used in commercial insurance settings, so they need to be closely monitored for their effects on consumers and on the clinicians responsible for their administration.” For more information, visit

Last Updated 08/10/2022

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