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Health Exchange Drug Plans Called Confusing

The hunt for a health plan that would cover a particular drug or a favorite doctor proved particularly frustrating for many consumers navigating the new insurance exchanges under the federal government’s health care overhaul, according to a report released Monday.

In nearly half the 85 health plans analyzed, it was difficult or impossible for people to determine what drugs were covered, according to the report by market research firm Avalere Health, the first systematic analysis of consumer experience on the exchanges.

The report analyzed health plans in five states that relied on the federal website, as well as state-run exchange plans in Washington, D.C., and a dozen states.

A directory of doctors was somewhat easier to find, but there were still some cases in which it was a very demanding search, the report found.

What’s more, the websites typically ranked plans by premium price, which could have misled patients who needed a specific costly medication if it wasn’t covered by the cheapest plan, Avalere spokeswoman Caroline Pearson said.

“It was very difficult for consumers to get a more nuanced view of what their plans covered,” Pearson said. In some cases, a consumer would have to click six times to find drug coverage information. Even worse, no links to lists of covered drugs existed for some health plans.

That forced consumers to search insurance company websites, and, even if they found the covered drug lists, it could be tough to determine which lists went with the exchange plans they were comparing, Pearson said.

“Many chronic conditions rely on medications for management and to keep people out of the hospital,” Pearson said. “If your drug is not covered, then you’re responsible for the full cost or you have to switch to a different drug. The impact on the patient could be several thousands of dollars a year.”

The situation should improve soon, Pearson said, noting the government will require plans on the federal exchange for 2015 to have direct links to lists of covered drugs, also known as formularies.

“It has long been difficult for consumers to tell what prescriptions are covered by different plans, which is why the health care law has taken steps to make this information more readily available,” said Health and Human Services spokesman Aaron Albright.

The pharmaceutical company Pfizer Inc. funded the analysis; Avalere maintained control over the content.

Nevada was the only state exchange the report analyzed with a tool to search for drugs so consumers could shop for a health plan based on their medications. But the tool didn’t estimate out-of-pocket costs and was confusing when trying to differentiate between different tiers of medications.

In this March 31, 2014 file photo, navigator John Jones explains the many options to a client seeking help buying health insurance at the Family Guidance Center in Springfield, Ill. (AP Photo/Seth Perlman, File)

Nevada’s website had other problems, which weren’t mentioned in the report, requiring officials to authorize a special enrollment period for thousands of people who may have tried to sign up but were thwarted by consistent errors. An independent auditor early this month said Nevada’s exchange failed to meet key performance benchmarks and recommended Xerox, its designer, be assessed penalties.

For each website, Avalere analyzed the accessibility of information for five health plans, scoring it by the number of clicks and whether a consumer would have to hunt from an insurance company’s home page or was directed to a dedicated page with the needed information.

“It’s very important that we focus on how to make plan comparison much easier than it was in most exchanges in the first year,” said Robert Krughoff, president of Consumers’ Checkbook, a nonprofit group that developed a model comparison tool with some features that several state-run exchanges are planning to add.

“None of the sites has done a good job helping consumers compare out-of-pocket costs,” Krughoff said. “That results in consumers wasting thousands of dollars a year.”


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