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 2.2 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 U.S. 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.

Questions Answered in This Report:

  • MCOs and Exchanges: What percentage of MCO PDs/MDs reported that their MCOs will offer a product on the exchanges that launched in 2014? Which types of benefit plans do MCO PDs/MDs predict will enroll the most beneficiaries? How many MCOs intend to use narrow provider networks in exchange-based plans? How many PDs/MDs expect their MCO to use the same formulary for their exchange and their traditional commercial plans? What percentage of those surveyed expect to use separate pharmaceutical and therapeutic committees for exchange plan formularies? Which branded asthma therapies are most likely to be placed on preferred tiers?

  • Physicians and Exchanges: What percentage of pulmonologists anticipates treating patients who receive coverage under the exchanges? What percentage of their patient base do they expect to be from exchanges? Will their prescribing patterns differ for exchange-based patients versus commercially based patients? How will their prescribing of various therapies differ in the exchange environment? What weight do prescribers give to various metrics, such as generic prescribing goals and hospital admissions, in the exchange and traditional commercial settings? Which features of healthcare reform will have the most positive effect on pulmonologists’ practices?

  • Use of Patient Assistance Coupon Programs in Exchanges. To what extent do MCOs and pulmonologists support the offering of discount coupons to help patients lower the costs of their asthma drugs? To what extent would MCOs and pulmonologists support the use of coupons in the insurance exchanges, if permitted by law, and why would they support it? With which discount programs are these stakeholders most familiar? To what percentage of their patients do pulmonologists offer coupons? For which therapies would pulmonologists most encourage patients to use coupons? How will MCOs respond to the use of coupons by exchange-based patients?

  • Treatment of Emerging Asthma Therapies. When leading branded asthma therapies are available in generic versions, what will be the impact on pulmonologists’ prescribing of branded therapies both on and off the exchanges? What percentage of pulmonologists’ asthma patients will be prescribed the latest emerging branded COPD therapy, GlaxoSmithKline’s Breo (vilanterol/fluticasone furoate), when it launches for asthma in 2014? What percentage of MCOs intends to cover Breo on preferred tiers in their commercial and exchange-based plans? On which metrics do MCO MDs/PDs place the greatest weight when determining formulary coverage of emerging therapies?

  • Medicaid Expansion: What percentage of MCOs’ beneficiaries is in Medicaid plans? How prevalent do MCO MDs/PDs believe asthma indications will be among the expanded Medicaid population? What percentage of Medicaid patients are prescribed which asthma drugs? For which therapies do pulmonologists face the most restrictions in Medicaid? How have the MCOs responded to lower rates from Medicaid? What percentage of pulmonologists’ asthma patients are in an MCO-operated Medicaid versus a state-run fee-for-service Medicaid program? To what extent do pulmonologists expect the type of coverage to influence their prescribing decisions for asthma drugs? Have they seen MCOs reduce coverage of asthma drugs in the Medicaid program?


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).

Epidemiology: Asthma.

Author(s): Chris Lewis

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