One of the most well-known aspects of the Affordable Care Act (ACA) is that of the prescription drug coverage plan, which significantly reduced the cost of brand name medications and increased coverage options for groups such as seniors. A new analysis from Avalere Health, however, reveals drug coverage under newly implemented ACA provisions will vary drastically by state.
In an effort to prevent premium increases, a new benchmark formulary has been introduced on the state level, reports American Medical News.
The benchmarks, called Essential Health Benefits (EHBs) define the benefits for prescription drug coverage under the new state insurance exchange.
While these EHBs cannot discriminate in terms of coverage benefits, they can define which drugs and how many drugs are covered under each plan in the exchange.
Drugs are broken down into classes, and if drug coverage for a class is undefined, an insurer in the exchange must provide coverage for at least one medication in that class.
The decision on how many drugs will be covered is ultimately left up to the state.
“In other words, if the benchmark plan covers 12 products in Class X and zero products in Class Y, then all [essential health benefits] plans in the state will have to cover 12 drugs in Class X and one drug in Class Y,” Caroline Pearson, a director at Avalere, told American Medical News.
The dilemma with the program, indicates critics, is many diseases require multiple medications from multiple drug classes to achieve successful treatment. If only one medication in a particular class is covered, the insurance will not be responsible for covering any additional medications from that class.
“Let’s imagine that you have arthritis and there are numerous drugs for treating pain. Some of them are anti-inflammatory drugs, and there’s a whole host of them,” explained Sonya Schwartz, program director at the National Academy for State Health Policy. “You may need to try many drugs in a class before you find one that works for you. If there’s only one [covered] drug per class, that might be difficult.”
Currently, the Avalere report indicates a significant swing in the benchmarks plans adopted by individual states. Some states only offer 45 percent prescription drug coverage under their EHB plans, while others offer 99 percent drug coverage.
Among the states with the lowest available drug coverage are Maryland, Michigan, North Carolina, Wisconsin, California and Minnesota, notes The Hill.