Review of Florida Qualified Health Plans: Implications for Plan Choices Jesse Fry Policy Analyst May 7, 2015.

Review of Florida Qualified Health

Plans:Implications for Plan

ChoicesJesse Fry

Policy AnalystMay 7, 2015

Overview: Review of Florida’s Qualified Health Plans

• Summaries of Plans’ Drug Benefits• Focus on Cost Sharing• How to access our full review – Electronic

Spreadsheet• Fluid environment• Links to health insurance company Web

sites• Frequency of updates; accuracy of online

formularies• Update on The AIDS Institute’s and NHeLP

complaint• Recent formulary and cost sharing changes

per OIRThe AIDS Institute

Florida Reasonable Cost-sharing Plans: 2015 - HIV

The AIDS Institute

QHP Issuer Benefit Design Cost-Sharing

Ambetter

• Almost all HIV Drugs on Tier 2 or 3• 2 Drugs on Tier 4

• Tier 2 Copay $50• Tier 3 Copay $100• Tier 4 Coinsurance 30%• Must first meet $1,000

Rx Deductible

Blue Cross• Almost all HIV Drugs on Tier 2• Some on Tier 3• Only 1 Drug on Tier 4

• Tier 2 Copay $70 • Tier 3 Copay $100• Tier 4 Copay $150

FL Health Care Plans

• All but 1 HIV Drug on Tier 3• Only 1 Drug on Tier 6 (with generic on

Tier 2)

• Tier 2 Copays Range $10 - $27

• Tier 3 Copays Range $30 - $87

• Tier 6 Coinsurance 20%• Must first meet $400 Rx

Deductible

The AIDS Institute

QHP Issuer Benefit Design Cost-Sharing

Humana

• 6 HIV Drugs on Tier 2• 7 Drugs on Tier 3• For 22 Drugs, on Custom Tier of

10% of Cost

• Tier 2 Copay $20• Tier 3 Copay $50• Must first meet $1,500 Rx

Deductible except for Tiers 1 and 2

Molina

• All but 2 HIV Drugs on Tier 2• 2 Drugs on Tier 4

• Tier 2 Copay $50• Tier 4 Coinsurance 30%• Must first meet $200 Rx

Deductible

United Healthcare

• Most HIV Drugs on Tier 2• A couple on Tier 3• 3 Drugs on Tier 4

• Tier 2 Copay $40• Tier 3 Copay $80• Tier 4 Copay $160

Florida Reasonable Cost-sharing Plans: 2015 - HIV

Florida High Cost-Sharing Plans: 2015 - HIV

The AIDS Institute

Issuer Benefit Design Cost-Sharing

Aetna & CoventryOne

• All but 1 Brand HIV Drug on Tier 5• Agreed to Cap Copay at $200 for 4

Drugs

• Tier 5 50% co-insurance• Must first meet $500 Rx

Deductible

Cigna• All Brand HIV Drugs on Tier 5• Agreed to Cap Copay at $200 for 4

Drugs

• Tier 5 30-50% coinsurance• Must first meet $2,750

Deductible

Health First• All HIV Brand & Generic Drugs on

Tier 5• Tier 5 30% co-insurance• Must first meet $500 Rx

Deductible• Prior Authorization for most

Preferred Medical

• All Brand HIV Drugs on Tiers 4 & 5• Agreed to Cap Copay at $200 for 4

Drugs

• Tiers 4 & 5 50% co-insurance

• Must first meet $1,500 Rx Deductible

The AIDS Institute

Issuer Benefit Design Cost-Sharing

Assurant

• All HIV Drugs on Tier 2

• No cost after $3,500 Deductible is met

• No cost-sharing information available

• Impossible to determine cost-sharing prior to enrollment

Florida Plans Unknown Cost-sharing: 2015 - HIV

Aetna/Coventry Nationwide Formulary Changes

• Oral Drugs on Generic or Non-Preferred Brand Tier

• Copayments Between $5 and $100 After Deductibles

• Certain plans have separate “prescription deductibles”

• Effective June 1, 2015 All Aetna and Coventry QHPs

• Nationwide, not just Florida• Will Also Apply to QHPs in 2016

The AIDS Institute

Review of Florida’s Qualified Health Plans in the Federal Marketplace

• Focus on quality review in terms of share of cost and drug formulary coverage

• The hope of more informed plan choices by people living with HIV and AIDS

• Reviewed only Silver Plans • www.theaidsinstitute.org/FloridaQHPreview• Encourage downloading the spreadsheet

often• Reasoning about network adequacy review

& lack of it

The AIDS Institute

Review of Florida’s Qualified Health Plans in the Federal Marketplace

• Focus on quality review in terms of share of cost and drug formulary coverage

• The hope of more informed plan choices by people living with HIV and AIDS

• Reviewed only Silver Plans • www.theaidsinstitute.org/FloridaQHPreview• Encourage downloading the spreadsheet

often• Reasoning about network adequacy review

& lack of it

The AIDS Institute

THANK YOUJesse Fry

Policy [email protected]