Prescription drugs: Harder to get in O-Care?

Prescription drugs: Harder to get in O-Care?
© Thinkstock

ObamaCare participants are twice as likely to face administrative barriers to using certain prescription drugs as people who receive health coverage through an employer, according to a new analysis.


The research from consulting firm Avalere Health points to a little-known facet of policies on the ObamaCare exchanges known as "utilization management controls."

The controls allow insurance companies to limit access to certain medications to try and control costs and prevent abuse. People who enroll in ObamaCare plans are likely to encounter the hurdles if they're prescribed brand-name cancer or mental health drugs, Avalere found.

At least 51 percent of brand-name mental health meds come with special controls on the exchanges, compared with only 11 percent on the employer-based market, the analysis found.

Researchers noted that the presence of controls for psychiatric drugs was possible but unknown on roughly one-third of exchange plans and 40 percent of employer-based plans.

Fewer hurdles exist, meanwhile, to HIV/AIDS drugs on the exchanges, where only one in five plans subjected the medications to special management. As expected, an even smaller number of plans on the employer market placed barriers in front of those medications.

Utilization management requires patients and doctors to take extra steps to show they're using prescription drugs properly.

The controls may include policies like "step therapy," when patients must try cheaper medications before receiving coverage for an alternative that costs more, or "prior authorization," which means an insurer grants coverage of prescriptions on a case-by-case basis.

Insurers argue the policies prevent abuse, lower risk to patients and decrease drug costs for everyone. Consumer advocates tend to oppose the controls, arguing they create frustrating and sometimes dangerous barriers to care.