Consumers should truly examine the plans available for purchase on the public exchange, not just compare the premiums. A recent study by Avalere Health compared 84 prescription drug formularies on bronze and silver plans in the 15 largest states and found a health plan purchased through the public exchange is twice as likely to require utilization management for prescription drugs compared to an employer sponsored plan.
For prescription drugs, utilization management is an administrative procedure a patient and doctor must complete to show the prescription is appropriate. Utilization management is used by health plans to limit access to certain medications and reduce costs.
Avalere Health’s study found utilization management to be four times more common for public exchange plans compared to employer sponsored plans, with 51% of brand name mental health drugs having special controls. Consumers on the public exchange who need access to brand name drugs should look at plans with open drug access due to these hurdles.