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Large portions of the Affordable Care Act (ACA) took effect in 2014, giving millions of Americans access to health insurance and prescription drug coverage for the first time in years. This report examines how the launch of health insurance exchanges and new rules for health plans affect reimbursement and prescribing for asthma in the marketplace versus Medicaid and traditional commercial insurance. Drug marketers must understand these issues as healthcare reform takes effect or risk falling behind competitors in serving the previously untapped market. Healthcare reform dramatically affects the managed care industry. Insurers have access to millions more beneficiaries through state and federally subsidized exchanges, which enrolled nearly million Americans as of December 28, 2013. The unknown health risks of the newly insured, coupled with new mandates that plans cover more services under certain financial constraints, have prompted insurers to tighten provider networks and drug formularies to control premiums in the new marketplace. The result has been drug benefits that more are more restrictive than commercial plans. Most beneficiaries, in search of lower premiums, are expected to enroll in those plan designs with the highest cost-sharing on services, such as prescription drugs. Healthcare reform is also prompting Medicaid’s biggest transformation since the program’s launch in the 1960s, opening up the system to an additional 17 million Americans (assuming all states eventually expand Medicaid), particularly uninsured adults earning up to 133% of the federal poverty level—thus entitling them to low- or no-cost drug coverage. However, only about half of states are expanding Medicaid as envisioned in the ACA; several other states are refusing expansion, and a handful are working out compromises with the federal government. Meanwhile, as the recession swelled the Medicaid ranks, states have been tapping managed care organizations (MCOs) to coordinate the program more efficiently. These plans often have their own formularies that must be approved by the government, but they still have discretion to impose utilization controls or exclude some drugs within a class. As Medicaid rolls grow further under reform, MCOs will play an increasingly larger role in access to asthma drugs.
This U.S. Physician and Payer Forum explores the dramatic expansion of Medicaid programs and coverage on exchanges under healthcare reform and how they will affect access to asthma drugs. Based on surveys of 100 pulmonologists and 40 MCO pharmacy and medial directors, the report gives drug marketers insight into how the emergence of insurance exchanges and the expanded Medicaid program will affect prescribing of asthma drugs.
Markets covered: United States.
Primary research: Online survey of 100 pulmonologists and 40 MCOs (27 pharmacy directors and 13 medical directors).