Comparing employer-sponsored and federal exchange plans: wide variations in cost sharing for prescription drugs.
Just under seven million Americans acquired private insurance through the new health insurance exchanges, or Marketplaces, in 2014. The exchange plans are required to cover essential health benefits, including prescription drugs. However, the generosity of prescription drug coverage in the plans has not been well described. Our primary objective was to examine the variability in drug coverage in the exchanges across plan types (health maintenance organization or preferred provider organization) and metal tiers (bronze, silver, gold, and platinum). Our secondary objective was to compare the exchange coverage to employer-sponsored coverage. Analyzing prescription drug benefit design data for the federally facilitated exchanges, we found wide variation in enrollees' out-of-pocket costs for generic, preferred brand-name, nonpreferred brand-name, and specialty drugs, not only across metal tiers but also within those tiers across plan types. Compared to employer-sponsored plans, exchange plans generally had lower premiums but provided less generous drug coverage. However, for low-income enrollees who are eligible for cost-sharing subsidies, the exchange plans may be more comparable to employer-based coverage. Policies and programs to assist consumers in matching their prescription drug needs with a plan's benefit design may improve the financial protection for the newly insured.
Christine Buttorff (buttorff@rand.org) is an associate policy researcher at the RAND Corporation in Arlington, Virginia.
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Martin S. Andersen is an assistant professor in the Department of Economics at the University of North Carolina at Greensboro.
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Kevin R. Riggs is a fellow in the Division of General Internal Medicine, Johns Hopkins University School of Medicine, in Baltimore, Maryland.
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G. Caleb Alexander is an associate professor in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health and codirector of the school's Center for Drug Safety and Effectiveness.
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D000328:Adult; D017047:Cost Sharing / Q000191:economics*; D003430:Cross-Sectional Studies; D005260:Female; D006264:Health Benefit Plans, Employee / Q000191:economics*; D062265:Health Insurance Exchanges / Q000191:economics; D006279:Health Maintenance Organizations / Q000191:economics; D006801:Humans; D007356:Insurance, Pharmaceutical Services / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D055553:Prescription Drugs / Q000191:economics*; D011785:Quality Assurance, Health Care / Q000191:economics*; D014481:United States
D055553:Prescription Drugs
Health Reform; cost sharing; health insurance; health insurance exchanges; prescription drug benefits