Atlantic Information Services Inc. (AIS) researchers examined the pharmacy-benefit parameters of risk-based commercial plans, offered in the individual and small-group markets during 2014, and found that coverage of specialty pharmaceuticals still differs widely among plans.
Their findings, published in the new “Specialty Pharmacy Trends and Strategies: 2015,” are based on information from AIS’s Rx benefit data.
AIS found that the majority of plans that use a fourth formulary tier for specialty drugs enforce a percentage-based member coinsurance for drugs covered under this tier. They also discovered that specialty pharmacy co-insurance amounts were up to $600 or 80 percent per prescription.
Furthermore, patients taking specialty medications are much more likely to be restricted to specific network pharmacies or specialty pharmacy providers for these fills, according to the findings.
AIS’s findings showed that these factors make it highly probable that patients on specialty medication will find cost-sharing levels to be taxing and will reach out-of-pocket maximums early in the year.
AIS suggests that plans offer health savings accounts in order to ease some of these problems. Pharmaceutical manufacturers, AIS said, can identify plans with high out-of-pocket limits and cost-sharing and target those members for patient-assistance programs.
For more information on "Specialty Pharmacy Trends and Strategies: 2015," visit www.aishealth.com.