US health exchanges' formulary policies begin to shape up

After health exchanges (aka “HIXs”) structured under the Affordable Care Act began to take in clients, questions arose as to how they would set up their formularies—which, in turn, creates a competitive marketplace for drugs. ACA requires at least one drug in each therapy class (and sometimes more, depending on the state); would the formularies be constrained to only that one drug, or allow for others? And a broader question: would formulary choices for HIXs influence formularies for commercial and other insurance plans?

Xcenda (Charlotte, NC), a consulting unit of AmerisourceBergen, has been running a “PayerPulse” survey of plan managers, and in its latest polling finds that—mostly—commercial plan structures have influenced the HIX plans, but less so in reverse (62% agreed that the commercial plan set the pace; only 28% said that their HIX influences their commercial plans). Specialty drug utilization was higher in 2014 than expected (something that nearly all plans have experienced); HIX managers will be controlling costs by instituting higher premiums and, about half the time, by increasing cost-sharing.

Xcenda notes that late last year, HHS proposed “allowing payers to use their own formulary review processes to develop their formularies for HIX plans, vs complying with the current policy mandating they include the same number of drugs per USP class that are in the states’ benchmark plan.” Ninety percent of the surveyed payers plan to align their HIX formularies with their current offerings or to streamline the number of products they cover by therapeutic area. The respondents were evenly split between those who plan to align HIX formularies with commercial formularies, and those that will streamline the number of drugs in a given therapeutic area.

The PayerPulse survey occurs across a swath of payers nationally, representing upwards of 150 million covered lives.