Dec. 19—Drug formularies with large coinsurance charges for the costliest drugs dominate among insurance plans sold in new government-run marketplaces, in sharp contrast to their limited use in employer-provided plans, according to a new analysis.

Avalere Health found most enrollees in marketplaces, also known as exchanges, created by the Affordable Care Act will face formularies with four or five cost-sharing tiers—with high coinsurance for specialty medications dominating among the highest tiers.

“Consumers relying on specialty pharmaceuticals should anticipate out-of-pocket costs tied to a percentage of their medication cost,” Caroline Pearson, vice president of Avalere, said in a web post. “With many specialty drugs costing several thousand dollars, this could require patients to outlay significant dollars before reaching out-of-pocket maximums.”

Such coinsurance-driven drug pricing tiers are a common cost-sharing technique among Medicare Part D plans, but they are relatively rare among employer-provided commercial insurance plans.

The analysis of more than 600 exchange plans found 91 percent of marketplace plans had formularies with four or more tiers, compared with just 23 percent in the employer market. The high patient cost sharing for specialty medications is similarly common among Medicare drug plans, 94 percent of which feature the high tier levels.

Insurers Extend Payment Time

In a separate development Wednesday, insurers agreed to give enrollees in marketplace plans more time to activate their coverage by paying their first premium. Consumers who select plans by Dec. 23 will have until Jan. 10 to pay their premiums for effective coverage on Jan. 1, the board of directors of America’s Health Insurance Plans (AHIP) announced Wednesday.

The new agreement extended the previous Dec. 31 due date of premiums for coverage effective Jan. 1.

The voluntary one-time change aims to prevent marketplace enrollees from having coverage lapses due to ongoing technical problems with the federal- and state-run insurance enrollment websites.

“Significant progress has been made in recent weeks to improve the enrollment process for consumers, but more work needs to be done to resolve the back-end challenges, particularly those related to processing enrollment files, to ensure all consumers who selected a plan are enrolled in coverage,” said an AHIP statement.

The insurers’ action followed a growing number of delays of ACA provisions by the Obama administration, including a recent 10-month suspension of ACA rules that would have required cancellation of many individual insurance market plans by Jan. 1.

Website Leadership Changed

Leadership of the federal website,, was transferred Wednesday from Jeffrey Zients to Kurt DelBene, a former Microsoft executive. Zients led an initiative to fix many problems at the malfunctioning site following a disastrous Oct. 1 launch.

“The president and I believe strongly in having one person, with strong experience and expertise in management and execution, who is thinking 24/7 about,” U.S. Health and Human Services Secretary Kathleen Sebelius said in a written statement. “Kurt’s leadership and management of will be in consultation with [Centers for Medicare & Medicaid Services] Administrator Marilyn Tavenner and in partnership with the project’s general contractor, QSSI.”

Rich Daly is a senior writer/editor in HFMA's Washington, D.C., office. Follow RIch on Twitter


Publication Date: Thursday, December 19, 2013