The Affordable Care Act changed the rules on how health insurance
plans dealt with pre-existing conditions, outlawing the practice of
turning away patients with expensive conditions or charging them a
drastically higher cost for coverage. But an editorial
alleges some health insurance companies operating on the new
marketplaces created by Obamacare may have found a loophole that allows
them to discourage sick patients from enrolling in a specific plan.
The change has to do with how drugs are categorized in health systems. From the editorial published online at the American Journal of Managed Care:
The change has to do with how drugs are categorized in health systems. From the editorial published online at the American Journal of Managed Care:
"For
many years, most insurers had formularies that consisted of only three
tiers: Tier 1 was for generic drugs (lowest copay), Tier 2 was for
branded drugs that were designated “preferred” (higher co- pay), and
Tier 3 was for “nonpreferred” branded drugs (highest copay). Generic
drugs were automatically placed in Tier 1, thereby ensuring
that patients had access to medically appropriate therapies at the
lowest possible cost. In these three-tier plans, all generic drugs were
de facto “preferred.” Now, however, a number of insurers have split
their all-generics tier into a bottom tier consisting of “preferred”
generics, and a second tier consisting of “non-preferred” generics,
paralleling the similar split that one typically finds with branded
products. Copays for generic drugs in the “non-preferred” tier
are characteristically much higher than those for drugs in the first
tier."
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