A Review of Behavioral Health
Benefits in Newly Reformed
Individual MarketplacesServices and Drug Coverage
Sponsored by
Produced by
Section I
A comparison of
behavioral and physical
health benefits as well
as provider networks in
Bronze and Silver
plans in five states.
Section II
An analysis of drug
coverage, utilization
management, and costsharing for 25 products in
nine states.
Speaker: JANE HORVATH
September 11, 2014
INTRODUCTION
Mental Health America and Takeda-Lundbeck
commissioned comparative research of Bronze
and Silver level individual market Exchange
plans in nine MHA- priority states (AZ, CA, CO,
IL, MD, MT, NJ, NY, TX).
SECTION I: A comparative review of services,
cost-sharing, and provider networks for
behavioral and physical health in individual
market Exchange plans in five of the nine
priority states.
SECTION II: A market scan of plan formularies
to assess coverage, tier placement, utilization
management, and cost-sharing trends for 25
antidepressants and bipolar therapies in the
individual market Exchange of the nine priority
states.
2
I
SECTION
BEHAVIORAL
HEALTH BENEFITS
AND PROVIDER
NETWORKS
SECTION I:
STUDY
QUESTIONS
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
• Cost-sharing
• Office visits, inpatient, outpatient?
• In-network, Out-of-network?
• Is BH included in OOP Maximum?
• Deductible
• Separate BH?
• Any services excluded?
• Access
• BH provider in-network?
• Prior authorization or referrals required for
access?
4
SECTION I:
METHODOLOGY
• Compared and contrasted the behavioral health
and physical health benefits in two Silver and
two Bronze metal level plans in the individual
market in the Exchanges of the most populous
regions of five MHA –priority states: AZ, IL, MT,
NJ, TX.*
• Used publicly available documents – plan
summary of benefits and coverage, plan
provider search functions.
• When available, only used data on providers
listed as accepting new patients but four plans
(20%) did not have this public capacity
• Assumed that unless otherwise specified, an BH
provider is considered a ‘specialist” in each plan
and patient access requires specialist-level costsharing
• Selected oncologists as comparator group to
psychiatrists after consultation with MHA.
• There may be duplication in provider counts
because some plan search functions include each
provider location as a distinct, countable provider.
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
*These are all Federally-Facilitated Exchanges which keep plan information
public outside of the open enrollment period. State exchanges had incomplete
data available for this analysis and thus were not included in this Section.
5
Findings:
BEHAVIORAL
HEALTH
SERVICE
ATTRIBUTES
No clear distinctions in
services/cost sharing
between metal levels or
states.
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
All plans appear to technically comply with
the Mental Health Parity and Addiction Equity
Act
• All plans have equal or comparable cost
sharing and utilization management
requirements for physical, mental and
behavioral health.
• There were no explicit service restrictions on
behavioral health services in any plan.
• Behavioral health cost sharing included in
the out of pocket maximum of all plans.
Service Coverage Highlights:
• 8 plans (40%) require prior authorization or
referral for specialist care
• 7 plans (35%) have no cost sharing for both
inpatient in-network behavioral health and
substance abuse services
6
Findings:
BEHAVIORAL
HEALTH
PROVIDER
NETWORKS
This research is not
sufficient to evaluate
network adequacy. All
these plans meet
federal requirements
for adequacy.
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
Nearly all plans included coverage for nonphysician providers, such as licensed clinical
social workers or licensed mental health
counselors. Depending on the plan behavioral
health providers may or may not include
psychiatrists.
Seven plans have over 350 behavioral health
providers in network, while nine plans have over
100 mental health providers in-network.
Six plans have fewer than 10 behavioral health
providers in-network.
Thirteen plans (65%) have a greater number of
psychiatrists than oncologists in-network.
Caveats:
• All plan provider network information may not be up to
date;
• Some plans do not provide information on which
providers accept new patients, and
• This research does not include demographic analysis that
might better answer a question of network adequacy.
7
With all the caveats about data quality and
sample size;
Summary:
BEHAVIORAL
HEALTH
PROVIDER
NETWORKS
Out of pocket costs appear to be equal to
physical health.
• Issues
• Is there behavioral health primary care?
• Are there clinical preventive services that
could be considered for first dollar
coverage?
Robust networks are not a guarantee of access.
• Did not study demographics of access: time,
distance, or income.
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
8
COMPARING BEHAVIORAL AND PHYSICAL HEALTH BENEFITS AND
PROVIDER NETWORKS
Inpatient, In-Network
Outpatient, Out-ofState
Plan
Humana Connect 6300/6300 Bronze
Arizona
BCBS Everyday Health Alliance 6000 Bronze
Humana Connect Silver
BCBS Everyday Health Alliance 4000 Silver
Blue PPO Bronze 006
Illinois
Humana Connect Bronze 6300/6300
Blue Choice Silver PPO 003
Humana Connect Silver 4600/6300
Access Care Bronze
SmartHealth Value Bronze 3000
Montana
PacificSource: SmartHealth Value Silver 3000
Connected Care Silver: Montana Health
Cooperative
New
Jersey
AmeriHealth NJ Tier 1 Advantage –
Bronze EPO
Horizon Advantage EPO Bronze
Horizon Advance EPO Silver
AmeriHealth NJ Tier 1 Advantage – Silver EPO
H.S.A.
Blue Advantage Bronze HMO 005
Blue Advantage Bronze HMO 006
Texas
Molina Marketplace Silver Plan
Blue Advantage Silver HMO 003
BEHAVIORAL HEALTH BENEFIT
AND PROVIDER COMPARISONS
Cost-Sharing
Behavioral Health vs.
Physical Health
Network Cost-Sharing
Behavioral Health vs.
Physical Health
Psychiatrists vs.
Oncologists
Overall Number of Behavioral
Health Providers*
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
<
>
>
>
>
>
>
<
<
>
>
<
<
>
>
<
>
>
<
>
592
X
=
=
X
=
=
=
=
7
589
7
0
1346
0
1346
5
189
190
4
22
45
45
22
399
399
21
399
> MORE PSYCHIATRISTS THAN ONCOLOGISTS
= BEHAVIORAL HEALTH AND PHYSICAL HEALTH COST-SHARING IS THE SAME
< LESS PSYCHIATRISTS THAN ONCOLOGISTS
X NO INFORMATION
* THESE NUMBERS DO NOT TAKE INTO ACCOUNT PROVIDERS LISTED AT MULTIPLE LOCATIONS. MAY
OR MAY NOT INCLUDE PSYCHIATRISTS.
MEDICAL
NECESSITY
DEFINITIONS
All plan summary of
benefits and coverage
refer to the ACA
Uniform Glossary for
the definition of
“medical necessity”
Medical Necessity“Health care services or supplies
needed to prevent, diagnose, or treat
an illness, injury, condition, disease,
or its symptoms and that meet
accepted standards of medicine.”
-ACA Uniform Glossary
• Developed by HHS and DoL
• Actual interpretation will likely develop
and be refined over time with federal
guidance, lawsuits, etc.
• Only two plans in this study specified the
need for a covered service to be
medically necessary
• Both are Illinois plans and the service
in question was primary care
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
10
In two states, Texas and Illinois, Silver plans had
higher cost sharing than Bronze plans—for both
inpatient and outpatient coverage.
Findings:
BRONZE
VERSUS SILVER
PLANS
From a behavioral
health/substance abuse
standpoint, Bronze vs.
Silver AV level was not
indicative of less cost
sharing or a stronger
provider network.
Five plans require no cost sharing for behavioral
health/substance abuse outpatient services.
• Four Bronze, one Silver.
Seven plans require no cost sharing for behavioral
health/substance abuse inpatient services.
• Four Bronze, three Silver.
Behavioral health provider network participation
seems more highly correlated to carrier/plan
sponsor than metal level.
Network participation information captured in this
analysis reflects all the shortcomings of the
carrier/plan public data.
BEHAVIORAL HEALTH BENEFIT AND
PROVIDER COMPARISONS
11
II
SECTION
FORMULARY
REVIEW OF
BEHAVIORAL
HEALTH
THERAPY
COVERAGE
•
Reviewed 25 behavioral health drug treatment therapies for
coverage in plans sold on the individual market Exchanges of
nine states using publicly available summaries of benefits and
coverage and drug formularies.
•
SECTION II:
METHODOLOGY
•
Where coverage varied based on dosage form or strength,
Breakaway captured information on the form/strength with the
least access restrictions.
•
States Reviewed
Arizona
California
Colorado
Illinois
Maryland
Montana
New Jersey
New York
Texas
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
•
Plans included were selected on the basis of largest
enrollment or plans in the most populous region of a state.
All averages are simply mathematical averages, not
weighted.
72 plans (36 Bronze, 36 Silver)
• 4 Bronze, 4 Silver per State
• 2 HMOs, 2 PPOs per State/per metal level where
possible (EPO and POS used in absence)
Products
Abilify
Brintellix
Celexa
Clozaril
Cymbalta
Efexor
Fetzima
Geodon
Invega
Latuda
Lexapro
Paxil
Pristiq
Prozac
Risperdal
Saphris
Savella
Seroquel
Viibryd
Zoloft
13
Zyprexa
Depakote
Lamictal
Lithane
Tegetrol
Average Coverage Rates of All 25 Behavioral Health
Therapies Within Each State
100%
AVERAGE
COVERAGE
RATES WITHIN
STATES
90%
95%
87%
84%
80%
70%
62%
83%
79%
62%
60%
50%
The average frequency of
coverage for 25 products among
8 plans in each the 9 states.
40%
All Exchange plans are required
by law to have an appeals
process to request a drug not
listed on a plan’s preferred drug
list.
20%
30%
10%
0%
N= 8 plans/state
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
14
75%
79%
Average Coverage Rates Across States by Metal Tier
Percent of Drug Lists/Formularies
AVERAGE
COVERAGE
RATES WITHIN
STATES
BY METAL
LEVEL
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96%
93%
90%
84%
84% 84%
64%
60%
84%
81%
88%
82%
76%
61% 62%
Arizona California Colorado
85%
73%
62%
Illinois
Bronze
15
Montana Maryland
State
Silver
New
Jersey
New York
Texas
Includes all drugs in all
plans across all 9 states.
Average Coverage Rates of Branded and Generic
Products
Percent of Drug Lists/Formularies
AVERAGE COVERAGE
RATES OF BRANDED
VS. GENERIC
THERAPIES
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
50%
94%
50%
6%
Branded
Generic
No
16
Yes
BRANDED
COVERAGE
FINDINGS
9 branded products
Abilify
Brintellix
Fetzima
Invega
Latuda
Pristiq
Saphris
Savella
Viibryd
• All drugs covered in each Metal level by at least
one plan
• Illinois and Texas
• No Difference in Coverage Count Among Metal
Levels
• Illinois, Texas, Colorado, Montana, New Jersey
• Greater Product Coverage in Bronze v Silver Plans
• Texas, California
• Greater Product Coverage in Silver v Bronze Plans
• Arizona, Maryland, New York
• No state had no coverage of brands in any metal
level
• Brintellix frequently excluded on one or both
levels
• Pristiq only excluded in Montana
17
Tiering Clusters of All Covered Products by Plan Type
100%
TIERING
“CLUSTERS” BY
PLAN TYPE
Percent of Drug Lists/Formularies
90%
80%
70%
65%
63%
61%
60%
50%
48%
40%
28%
30%
23%
20%
Count of covered products by tier
across all 72 plans and across all
9 states.
11%
13%
8%
10%
22%
20%
9%
6%
9%
6%
0%
2%
3%
0%
0%
Tier 1
Tier 2
HMO
•
Tier 3
PPO
EPO
Tier 4
•
Plan Does Not
Specify
POS
Drugs with high rates of coverage are
placed on Tier 1
• Celexa, Lithane, Risperdal, Lexapro
Infrequently covered drugs, when
covered, are commonly on Tier 3
• Viibryd, Brintellix, Fetzima, Saphris
FORMULARY REVIEW OF
BEHAVIORAL HEALTH THERAPIES
1%
18
Tiering Averages of All Covered Products by Metal Level
TIERING
“CLUSTERS” BY
METAL LEVEL
Count of covered products across
all 72 plans across all 9 states
Percent of Drug Lists/Formularies
100%
90%
80%
70%
60%
61%
53%
50%
40%
28%
23%
30%
20%
12% 9%
10%
1%
0%
Tier 1
Tier 2
Tier 3
Bronze
•
Tier 4
•
Plan Does
Not Specify
Silver
Drugs with high rates of coverage are
placed on Tier 1
• Celexa, Lithane, Risperdal, Lexapro
Infrequently covered drugs, when
covered, are commonly on Tier 3
• Viibryd, Brintellix, Fetzima, Saphris
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
8%
4% 2%
19
Tiering Clusters of All Covered Products By State
100%
90%
Count of covered
products across all 72
plans across all 9 states
80%
77%
70%
Percent of Drug Lists/Formularies
TIERING
“CLUSTERS”
BY STATE
70%
60%
63%
59%
59%
59%
57%
53%
51%
50%
40%
29%
28%
30%
26%
27%
27%
21%
15%
20%
11%
12%
10%
14%
12%
10%
9%
7%
6%
23%
19%
2%
1%
1%
0% 0% 0%
5%
2%
12%
12%
9%
9%
0%
1%
0%
0%
0%
0%0%
0%
Tier 1
Tier 2
Tier 3
Tier 4
Tier
Arizona
Maryland
FORMULARY REVIEW OF
BEHAVIORAL HEALTH THERAPIES
California
New Jersey
20
Colorado
New York
Illinois
Texas
Plan Does Not
Specify
Montana
OVERVIEW OF FINDINGS
FINDINGS
COST SHARING
• Use of prescription-only deductibles
in 4 states: AZ, CA, IL, MD
• Lowest in CA ($250)
• Varies significantly by metal
level
• Little variation in copays and
coinsurance by metal level
• High rates of utilization
management, especially quantity
limits
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
21
Average Rx-Only Deductible Across States
$1,400
$1,167
AVERAGE
PRESCRIPTIONONLY
DEDUCTIBLES
BY STATE
Average Rx Deductible
$1,200
$1,000
$1,000
$800
$778
$730
$600
$400
$250
$200
$-
Arizona
California
Illinois
Maryland
Overall
State
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
•
Only 4 states analyzed used a
prescription-only deductible, with CA’s
being significantly lower than the rest.
•
The other states in the study used
combined (medical+prescription)
deductibles, which were not captured in
this analysis.
22
Average Rx-Only Deductible by Metal Level
$1,600
$1,400
Average Rx Deductible
AVERAGE
PRESCRIPTIONONLY
DEDUCTIBLES
BY METAL LEVEL
$1,500
$1,200
$1,000
$698
$800
$778
$600
$400
$200
$-
Bronze
Silver
Overall
Metal Level
• Among the 4 states using a prescriptiononly deductible
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
23
COST-SHARING
IN PLANS WHERE
RX EXEMPT
FROM ANY
DEDUCTIBLE
BY METAL LEVEL
$40
Dollars
Average copays by metal level
across all states and among all
plans that exempt Rx from any
deductible.
Average Copay in Plans Where Rx Exempt From
Combined Deductible
$28
$30
Bronze
Silver
$30
$20
$10
$-
Metal Level
Only includes plans that specify a
copay amount.
FORMULARY REVIEW OF
BEHAVIORAL HEALTH THERAPIES
24
Average Copay Before Deductible is Met
$35
$30
$30
$25
Dollars
AVERAGE COSTSHARING WHEN
DRUGS APPLY TO
DEDUCTIBLE
BY METAL LEVEL
$17
$20
$15
$10
$5
$-
Bronze
Average cost-sharing among all plans
and across all states
Metal Level
Only includes plans that specified a costsharing value greater than $0 or 0%
Average Coinsurance Before Deductible is Met
Percent
Top chart is average copay before any
deductible is met by metal level
Lower chart is average coinsurance
before any deductible is met by metal
level
Silver
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
100%
100%
Bronze
Silver
Metal Level
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
25
AVERAGE COSTSHARING WHEN
DRUGS APPLY TO
DEDUCTIBLE
BY METAL LEVEL
Dollars
Average Copay After Deductible is Met
$16
$14
$12
$10
$8
$6
$4
$2
$-
$14
$3
Bronze
Average cost-sharing among all plans
and across all states
Silver
Metal Level
Only includes plans that specified a
cost-sharing value
Average Coinsurance After Deductible is Met
Top chart is average copay after any
deductible is met by metal level
100%
Lower chart is average coinsurance
after any deductible is met by metal
level
Percent
80%
60%
40%
23%
11%
20%
0%
Bronze
Silver
Metal Level
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
26
Utilization Management Rate Among HMO Plans
AVERAGE
UTILIZATION
MANAGEMENT
BY PLAN TYPE
Percent of Drug Lists/Formularies
100%
100%
100%
90%
80%
81%
77%
76%
81%
81%
81%
80%
70%
60%
57%
52%
50%
67%
62%
54%
41%
35%
40%
31%
31%
36%
31%
31%
30%
20%
10%
0%
0%
0%
0%
0%
Product
Branded
Key takeaway:
Utilization Management Rate Among PPO Plans
100%
100%
Percent of Drug Lists/Formularies
Slightly higher application of
UM in HMO plans with a
similar, though less frequent,
pattern across drugs among
PPO plans
94%
90%
80%
94%
89%
86%
78%
69%
70%
56%
60%
50%
43%
38%
40%
30%
29%
26%
4%
13%
8%
0%
13%
8%
0%
0%
0%
FORMULARY REVIEW OF
BEHAVIORAL HEALTH
THERAPIES
38%
29%
21%
20%
10%
94%
23
Branded
Product
Generic
4%
Rates of Utilization Management Type of UM By State
100%
AVERAGE RATE
OF UTILIZATION
MANAGEMENT
BY STATE AND
TYPE OF UM
Key takeaways:
Quantity limits most common UM
approach
Step therapy is a significant UM
approach
Percent of Drug Lists/Formularies
90%
80%
70%
60%
52%
50%
50%
42%
40%
37%
37%
36%
30%
20%
10%
20%
16%
15%
10%
13%
10%
1% 1%
21%
18%
17%
12%
3%
3%
8%
3%
5%
4%
0%
0%
State
Quantity Limits
FORMULARY REVIEW OF
BEHAVIORAL HEALTH THERAPIES
28
16%
Step Therapy
Prior Authorization
0%
Few differences in cost-sharing
between Bronze and Silver plans
KEY
FORMULARY
TAKEAWAYS
Branded products covered less often
and placed on Tier 3 when covered
High utilization management rates,
particularly for branded drugs
Quantity limits used heavily in most
states
No readily available information to
indicate disparate treatment of
behavioural health/substance abuse
services from physical health.
29
A Review of Behavioral Health
Benefits in Newly Reformed
Individual MarketplacesServices and Drug Coverage
Sponsored by
Produced by
Speaker: JANE HORVATH
September 11, 2014
A P P E N D I X
COVERAGE
RATES OF EACH
DRUG BY STATE
Coverage Rate Among 8 Colorado Plans by Metal Level
100%
100%
100%
100%
100%
100%
100% 100%
100%
100% 100%
100%
Percent of Drug Lists/Formularies
90%
80%
75%
75%
75%
75%
75%
62%
61%
70%
60%
50%
50%
40%
30%
20%
10%
0%
0% 0%
0%
0%
0% 0%
0%
0%
0%
0%
0% 0%
0%
0%
Product
Branded
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
Bronze
32
Silver
0%
0%
Coverage Rate Among 8 Illinois Plans by Metal Level
100%
100% 100%
100%100% 100%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100%
93%
Percent of Drug Lists/Formularies
90%
80%
75%
70%
60%
50%
50%
50%
40%
30%
96%
25%
25%
20%
10%
0%
Product
Branded
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
Bronze
33
Silver
Coverage Rate Among All 8 New Jersey Plans by Metal Level
100%
100%
100%
100%
100%
100%
100% 100%
100%
100%
100%
100%
100% 100% 100% 100% 100%
100%
90%
Percent of Drug Lists/Formularies
82%
80%
75%
75%
75%
75%
75%
75%
70%
60%
50%
50%
50%
50%
50%
50%
50%
40%
30%
20%
10%
0%
0%
0%
0%
0%
Product
Branded
FORMULARY REVIEW OF BEHAVIORAL
HEALTH THERAPIES
Bronze
34
Silver
0%
0%
76%