Access

to Medicines for Chronic Conditions on Access Health Connecticut

In recognition of the critical role prescription medicines play in preventing the onset and progression
of many chronic conditions, the Affordable Care Act (ACA) includes prescription medicines as an
essential health benefit that health plans must cover. To meet ACA requirements, health plans have to
cover the greater of the same number of medicines per class as a designated benchmark health plan or
at least one medicine per category and class. There are no federal requirements or requirements from
the state of Connecticut regarding what tier or cost sharing level the plans place medicines on their
formularies.

Though the ACA prohibits discriminating against consumers because of their health status, what
constitutes discrimination is not defined. Placing all or substantially all medicines to treat a specific
health condition at the highest cost-sharing level would likely deter consumers with that condition
from choosing that health plan. Such practices could also disrupt the market by skewing the risk pool
among competing plans.

We analyzed the publicly available formularies for the four insurers offering health plan options
through Access Health Connecticut1 and compared them to the 2015 formulary for the benchmark
plan selected for Connecticut2 for five conditions: HIV, Cancer, Multiple Sclerosis, Rheumatoid
Arthritis, and Cystic Fibrosis. We chose these diseases because their treatment relies heavily on
affordable access to medicines, the mix of branded and generic medicines available for these
conditions, and the overall expense of treating these conditions. To identify cancer medicines, we
relied on the most expansive formulary available and supplemented that list with information from the
National Cancer Institute. Though this information is comprehensive, it is not an exhaustive list of
medicines used to treat the many forms of cancer. Links to resources used to identify cancer
medicines and medicines for the other chronic conditions included in this analysis are provided in the
appendix.

Each of the formularies is organized into Tiers. Tiers relate to out-of-pocket costs for consumers with
Tier 1 relating to the lowest out-of-pocket costs. In general for the plans analyzed, the first tier
includes primarily generic medicines. The second tier includes a mix of generic medicines and
preferred brand medicines. The higher tiers primarily include only brand medicines. The benchmark
health plan and Plan 4 in the study offer three-tier formularies or three levels of cost sharing for
consumers. The other insurers have four-tier formularies or four levels of cost sharing. While the
standardized cost sharing set by Access Health Connecticut in 2015 provides strong protection against
unaffordable out-of-pocket costs for patients who need medicines placed on the highest tier, we still
thought that it was important to examine tier placement for chronic condition medicines. First, not all

1 All four insurers use the same formulary of covered medicines for the health plan options they offer. Accordingly, the list of
medicines covered is the same for Bronze, Silver, Gold, and Platinum plans offered by a specific insurer in the exchange.
2 We pulled the current formulary for the Benchmark plan in Connecticut. Though an earlier version of the formulary was
used to set the benchmark, using the current formulary ensures that newer medicines and any new generic medications are
reflected in the mix.


plans sold on Access Health Connecticut use the standardized cost sharing. In fact, half of the plans in
the states exchange use non-standard cost sharing that are permitted to have high coinsurance for
medicines. Second, the standardized cost sharing levels could rise in future years, leaving patients
more vulnerable to unaffordable cost sharing for medicines placed on the highest tier.

Exchange Formularies for HIV

40

# of Medicines

35

30
25

2
12

Tier 4
24

20
15
10
5
0

28

15

Benchmark
in 2015

30

Tier 3
Tier 2
Tier 1

7
1

Plan 1

Plan 2

Plan 3

Plan 4

20

Plan 2 places all HIV medicines on the highest cost-sharing tier, including generics.
Plan 3 places all but one HIV medicine at the highest cost-sharing tier, including generics.
For this analysis, combination medicines are counted separately from single molecule products.
While the current Essential Health Benefit rules do not directly recognize combination products,
these products are the standard of care for HIV3 and therefore were included in this analysis.

3 M. Libre, et al. Clinical implications of fixed-dose combinations of antiretrovirals on the outcome of HIV-1 therapy. AIDS,
25(14): 16831690, 10 September 2011.
2

Exchange Formularies for Cancer

140

# of Medicines

120
100

67

Tier 4

80
16

60
40
20
0

51
7
16
Benchmark
in 2015

28

53
68

29
Plan 1

2
Plan 2

Tier 3
Tier 2

36

3
5
13

20

Plan 3

Plan 4

Tier 1

Plan 1 includes many physician-administered medicines that may not be reflected in other
formularies, but may be covered through those plans medical benefits. In general, insurers do not
publish a list of covered medicines administered by physicians covered under the medical benefit.
Plan 2 has all cancer medicines on highest tier except 2 medicines that are also approved for uses
other than treating cancers.

Exchange Formularies for Multiple Sclerosis

12

# of Medicines

10
8

Tier 4

11

10

4
2

Tier 3
Tier 2
Tier 1

0
Benchmark
in 2015

Plan 1

Plan 2

Plan 3

Plan 4

Plans 1, 2 and 3 place all medicines for multiple sclerosis on the highest cost-sharing tier.

Exchange Formularies for Rheumatoid Arthritis

20
18
# of Medicines

16
8

14
12
10

10

Tier 4
7

Tier 3

8
6

Tier 1

1
1

Benchmark
in 2015

Plan 1

Plan 2

Plan 3

Plan 4

Tier 2

These counts only include DMARDs (disease-modifying agents), including biologic response
modifiers, and exclude steroids and NSAIDs (such as ibuprofen).

Exchange Formularies for Cystic Fibrosis

6

# of Medicines

5
4
1
3

2
5

4
1

Tier 4
Tier 3
Tier 2
Tier 1

1
0
Benchmark
in 2015

Plan 1

Plan 2

Plan 3

Plan 4

Plan 2 did not have any medicines for cystic fibrosis listed on the formulary within the Respiratory
class of medicines. While plans are required to cover at least one medicine in each therapeutic
class, these classes are often relatively broad. In the case of cystic fibrosis and many other
conditions, treatments are included in broader classes along with medicines that do not treat that
condition. Thus, it is possible that a plan could meet the formulary requirements under Essential
Health Benefits and not cover any medicines for cystic fibrosis.
Plans 1 and 3 placed all medicines for cystic fibrosis at the top cost-sharing level.


Appendix


Links to Drug Formularies Used

Benchmark in 2015: ConnectiCare HMO (Note this is not the same plan or formulary used for
exchange plans by this insurer.) -
http://www.connecticare.com/GlobalFiles/PharmacyCentral/ConnectiCare%20Formulary%2
0-%20Chart.pdf
Plan formularies from the healthcare exchange (listed alphabetically):
o Anthem - http://www.anthem.com/CTSDL2015.pdf
o ConnectiCare -
http://www.connecticare.com/globalfiles/PharmacyCentral/cciexchangedruglist.pdf
o HealthyCT Inc. -
https://informedrx.rxportal.sxc.com/rxclaim/IRX/HEALTHYCT_EHB%20UNIV_%20(3
).pdf
o United Healthcare -
http://xct.welcometouhc.com/files/xct/content/CT%203%20Tier%20Trad_final.pdf

Resources for Identifying Medicines for Each Condition:

o General Drug Search: MedLine Plus -
http://www.nlm.nih.gov/medlineplus/druginformation.html
o HIV/AIDS: National Institutes of Health - http://aidsinfo.nih.gov/education-materials/fact-
sheets/print/21/58/0/0
o Rheumatoid Arthritis: Arthritis Foundation - http://www.arthritistoday.org/arthritis-
treatment/medications/drug-guide/search-by-
condition.php?v=9&condition=Rheumatoid%20arthritis
o Multiple Sclerosis: National Multiple Sclerosis Society -
http://www.nationalmssociety.org/Treating-MS/Medications
o Cancers: National Cancer Institute - http://www.cancer.gov/cancertopics/druginfo/alphalist
o Cystic Fibrosis: Stanford University CF Center -
http://web.stanford.edu/group/cfcenter/Meds.html