Update on Exchange Prescription Drug Coverage

 As time passes, it is becoming clear that policies purchased from an exchange will require more and more time from policyholders and their doctors to monitor payments and to meet new responsibilities which have become a prerequisite to being reimbursed. 

Prescription Drug Coverage

If you have an exchange policy, the days of having your doctor call in a prescription and then you going to the pharmacy of your choice and picking it up are becoming a thing of  the past.  Exchange policies are unlikely to offer open access to drugs used regularly. 

Insurance companies are implementing ”utilization management controls” which must be complied with in order for you to receive reimbursement for your prescription drugs.  This means that patients and their physicians must complete additional paperwork to demonstrate appropriate use of the drug being prescribed.  By doing this, drug companies can limit access to specific medications and, more importantly, reduce costs.  

Doctors are now being asked to fill out additional, complex paperwork to get their patients covered by their insurance companies.   If physicians do not comply with new and confusing utilization requirements, patients may not be able to get the drugs their doctor says they need. 

Worse, consumers will have to pay for the cost of controlling costs.  Copayments and co-insurance fees for drugs increased an average of 34 percent under ACA. Greatest impact was felt in the cost of brand-name drugs and specialty drugs.

 ‘Analysis from Avalere Health concluded that consumers purchasing insurance through the exchanges are twice as likely to face utilization management controls on prescription medications compared to people with employer-sponsored coverage.   Patients who use brand-name, cancer or mental health drugs are more likely to encounter this problem under PPACA.  For example, fifty one percent (51%) of brand-name mental health meds have special controls on the exchanges, compared with only eleven percent (11%) on the employer-based market.’  (Source: Rx hurdles high under some PPACA plans, By Kathryn Mayer, March 24, 2014 Benefits Pro Magazine)