Specialty drug coverage varies across health plans

April 6, 2015

Coverage of specialty pharmaceuticals varies widely among health insurers, according to a new report from Atlantic Information Services in Washington, D.C.

Coverage of specialty pharmaceuticals varies widely among health insurers, according to a new report from Atlantic Information Services in Washington, D.C.

Related: 5 ways to manage specialty drug expenses

Among plans that utilize a fourth formulary tier for specialty drugs, the majority impose a percentage-based member coinsurance for drugs covered under this tier. In addition, AIS found in its “Specialty Pharmacy Trends and Strategies: 2015” analysis that specialty pharmacy coinsurance amounts up to $600 or 90% per script.

Related: Hospital pharmacists protest higher cancer drug costs in survey

Plus, patients taking specialty medications are much more likely to be restricted to specific network pharmacies or specialty pharmacy providers to fill prescriptions. Even when out-of-network benefits are available at other formulary tiers, they are often not offered at the specialty tier.

Related:Specialty drugs: a good value, despite high cost

“This combination of factors makes it highly likely that patients on specialty medications will find cost-sharing levels to be burdensome, and will hit their out-of-pocket maximums early in the plan year,” according to a statement from AIS. Plans can mitigate some of these burdens by offering health savings accounts while pharmaceutical manufacturers can identify plans with high out-of-pocket limits and costing sharing and target those members for patient assistance programs, according to AIS.

At the same time, more specialty medications are being covered under the prescription drug benefit, which allows payers to take advantage of more cost management strategies than are available for medications covered under the medical benefit.

AiS examined the pharmacy benefit parameters of the universe of risk-based commercial plans offered in the individual and small-group markets during 2014. The company’s findings are based on information from AIS’s Rx Benefit Data (RxB), a new online subscription resource with detailed data, news and insight on prescription drug benefit parameters of commercial health plans.