Opponents of the ACA have raised the issue of drug formularies as a negative aspect of the new ACA-compliant plans, complaining that the new plans won’t cover all of the medications people need. Just like many of their previous arguments against Obamacare, this one lends itself to plenty of sound bites, and the basic premise is all about fear mongering rather than reality.
The concern is that non-formulary drugs aren’t covered and could leave people with significant out-of-pocket costs if their drugs are not counted towards the out-of-pocket maximum on the policy. There has also been some frustration with how difficult it can be to track down exactly which drugs are included on each plan’s formulary.
With regards to some medications not being covered, that has always been the case. This helpful article was published four years ago. If you spruced it up with some references to the ACA and exchanges and benchmark plans, it could easily pass for a new article about how prescription drugs are covered.
No, health insurance policies do not cover every drug approved by the FDA. They didn’t in the past, and they still don’t. Plans are required to cover at least one drug in each category, OR as many drugs in each category as the benchmark plan covers, whichever is greater. Under the ACA, each state had to select a benchmark plan on which new individual and small group plans would be modeled. In September 2012, Colorado selected a Kaiser small group plan, which was generally well-received by consumer advocate groups in the state (ie, it’s a good policy). Now that Colorado’s individual plans are being designed to largely mimic the benchmark plan, the coverage provided by individual plans is just as good as that of group plans, which was not always the case in the past. EDIT, 2/20/14: Although the Kaiser small group benchmark plan is generally considered to be very good coverage, it’s drug formulary is not as extensive as those of other benchmark plans across the US. There are roughly 1,040 “unique chemical entities” available in the US, and the average benchmark plan covers about 87% of them. The Kaiser benchmark plan in Colorado covers 54% of the unique chemical entities – the lowest percentage of any of the benchmark plans in the country. Although this is still far better than some of the old individual plans that didn’t cover prescriptions at all, or covered only generics and low-priced brand name drugs, it’s certainly not as good as many of the other benchmark plans. This means that if you’re taking high-priced medications, it’s especially important to double check the formularies of the plans you’re considering.
EDIT, 3/2/14: Please see Maggie Mahar’s comment at the bottom of this article. Although it’s important for people shopping for a new health insurance plan in Colorado to be aware of the drug formularies and double check to see if the plan they’re considering includes coverage for their medications, a more restrictive formulary is not necessarily worse than one that includes more medications.
Over the past decade, individual plans in Colorado had been slowly cutting back on prescription coverage in response to rising medication costs. Although most individual plans still covered prescription drugs, Rx deductibles were becoming very common, as were policies that limited coverage to only tier 1 and 2 drugs, or in some cases, only generic drugs. And there were also policies available that didn’t cover prescription drugs at all.
Those plans are no longer for sale. There is no such thing as a new policy that doesn’t cover prescriptions, or that limits coverage to only generics or low-cost brand names. To skewer the new plans because they don’t cover every FDA-approved medication is disingenuous at best. Critics are ostensibly looking out for consumers’ healthcare needs, but where were they when policies were being sold that didn’t cover any medications at all?
It’s true that if you are prescribed a drug that is not on your carrier’s formulary, you may have to pay the full price of the medication and it won’t necessarily count towards your out-of-pocket maximum (this is the case with ANY non-covered expense, including out-of-network charges for plans that do not have out-of-network coverage). But your doctor should be able to prescribe you a similar medication from the same class that is on your health plans’s formulary. If they cannot, and the non-covered medication is the only viable option, you and your doctor can work with your health insurance carrier to receive prior authorization to have the drug covered.
Connect for Health Colorado (should) make it very easy to see what medications are on each plan’s formulary. When you’re browsing plans, each one has a link to the plan details, and under that is another link to the “preferred drug list”. Clicking on that link (is supposed to) bring up the plan’s formulary, along with details about how prior authorization can be obtained for drugs that are not on the list, and how patients can request that new drugs be added to the list. As an example, here is Anthem Blue Cross Blue Shield’s 2014 formulary and related FAQs that they have posted on the Connect for Health Colorado website. That feature doesn’t work as of 9/17/2014, but will hopefully get fixed.
Don’t let people who are selling fear convince you that the new plans offer inferior prescription coverage. When compared with old plans that could be sold with no prescription coverage at all, the fact that the new plans don’t include ALL drugs seems like splitting hairs.
