ACA exchange plans are making some drugs more accessible to patients in 2016. Plans are less likely to place all drugs for conditions, such as HIV, cancer, and multiple sclerosis (MS) in a class on the highest cost-sharing tier, according to a report by Avalere. The study looked at Silver plans across 20 classes of medications. In five medication classes, some plans all drugs on the highest tier including drugs to treat HIV, cancer, and MS. However, fewer exchange plans are doing so in 2016 than in the prior two years.
As in prior years, the anti-angiogenics class, used to treat cancer, was most often subject to universal placement on the specialty tier. Half of all Silver plans placed all covered drugs in this class on the specialty tier in 2016. Nearly one-third of Silver plans place all covered MS drugs on the specialty tier as well, though this rate is down 14% from 2015. The sharpest decline is for molecular target inhibitors at 18%. For these three classes, 2016 reversed the sharp increase in this tiering structure.
Since the launch of exchanges in 2014, patient groups and policymakers have considered how formulary designs could affect patients’ ability to access medications. At the same time, plans strive to offer innovative benefit designs with low premiums. CMS has issued guidance discouraging plans from placing all drugs for a condition on the highest tier without regarding the cost of the medication. The federal government has not yet created a tool for regulators to evaluate benefit designs in this regard. California passed legislation preventing plans from placing all drugs for a condition on the highest formulary tier beginning in 2017