Original article authored by Michelle Rosenfeld of California Healthline, August 26, 2015.
The Affordable Care Act guarantees that 10 “essential health benefits” — including coverage of prescription drugs — will be included in every plan sold through the law’s insurance exchanges.
But there’s a catch.
Health plans offered through the ACA’s exchanges are required to cover prescription drugs, but insurers get to decide their own drug formularies, and those can vary significantly from plan to plan. And while insurers — both on and off the exchange — are required to publicly post details of their drug coverage policies, the formularies often are “incomplete, inaccurate or difficult to navigate due to lack of standardization and confusing or inaccessible consumer cost information,” according to a California-based study released this month by the California HealthCare Foundation. CHCF publishes California Healthline.
These issues can lead to consumers signing up for plans and then being surprised to find that their necessary or preferred medications are not covered in the same way as in their previous health plans. But for many consumers, the problems are even more basic than that: some aren’t able to find the formularies in the first place, or understand the drug coverage once they have.
Consumers Face Problems Finding, Understanding Formularies
Consumers in the California study were unfamiliar “with many of the terms used routinely in prescription benefit information” — including the words “formulary,” “co-insurance” and “prescription drug tiers.”
Further, researchers found that while “many consumers had not thought about checking whether their medications would be covered prior to selecting a health plan, those who did look for the information had difficulty locating it.” In fact, consumers reported that finding drug information was “frustrating and time-consuming,” with some noting that the process “lasted several weeks.” In addition, the CHCF study found that “[n]either agents nor counselors reported routinely helping clients conduct such drug benefit searches.”
