Affected Disease Groups/Conditions

Insufficient transparency, limited access, and reduced coverage in the health exchange plans affect some consumers more than others.

Individuals with mental health issues and chronic or other diseases, such as cancer, arthritis, and HIV/AIDS, are more adversely affected because:

  • The medications and other treatments they require may not be covered, or are covered on a high cost-sharing tier, by exchange plan formularies.
  • They may not have access to certain specialists given the limited nature of exchange provider networks.
  • Their health care costs generally represent a much higher percentage of their living expenses than the average patient.

High deductibles, dual co-pays, and expensive co-insurance rates put the people who most need consistent health care at risk of not being able to access the providers, treatments, and medicines they need.


Currently, exchange plans cover only 68% of asthma prescription drug treatments for which there is no generic option.

This may be sufficient for those patients needing only a single asthma medicine, but the many patients who need multiple treatments may have trouble accessing all of the medicines prescribed by their health care providers.

In addition to failing to cover some treatments at all, cost sharing for asthma medicines sometimes exceeds 30%, and asthma treatments are often subject to utilization management.


Many classes of oncology medicines are subject to extraordinarily high cost sharing in health exchange plans, and treatments are often subject to prior authorization. These factors limit access for many patients.


Sixteen percent of the time, Silver plans have co-insurance rates higher than 40% for key types of medicines used to treat cancer. Monthly out-of-pocket costs for such therapies could range from $375 to $6,000. Utilization management—typically prior authorization —also occurs 39% of the time for brand-name cancer treatments.


Exchange plans cover 57% of diabetes medicines, on average. This coverage is relatively robust compared to the coverage of other pharmaceutical classes. However, the most innovative treatments are often excluded, despite the fact that they work better for many patients.

Co-insurance for brand-name anti-diabetic treatments exceeds 40% more than 20% of the time in exchange plans. Co-insurance for insulin treatments exceeds 40% about 16% of the time. These co-insurance rates could result in annual out-of-pocket costs between $600 and $4,000.


HIV/AIDS treatments are generally well represented in exchange plan formularies in comparison to similar treatments for other conditions. Nonetheless, the combination therapies that are often the preferred treatment for HIV/AIDS are less likely to be included.

HIV/AIDS medicines are also subject to co-insurance in about 55% of plans, with a 35% average rate for all medications and 37% for combination therapies. That means HIV/AIDS patients in 2014 could expect to see out-of-pocket costs between $1,000 and $6,350 on an annual basis.

Mental Health

Health exchange plans provide coverage for an average of 66% of those prescription drugs for which there is no generic alternative used to treat mental health conditions. However, the newest and most innovative antipsychotic treatments are only included in about 26% of exchange plan formularies.

Mental health medicines are also often subject to high co-insurance, and 77% of the four classes of mental health medicines are subject to utilization management.

Multiple Sclerosis

Health exchange plans cover most brand-name multiple sclerosis medicines, but the plan design’s cost sharing is high, limiting access for low- and middle-income patients.

Silver plans require co-insurance for multiple sclerosis treatments about 75% of the time, with an average rate of 34%. This translates into out-of-pocket costs ranging from $250 to $1,700 for a month’s supply of just one treatment. This is especially problematic for patients with high deductibles.

At the same time, utilization management is an extremely common practice for multiple sclerosis medicines, occurring in 90% of exchange plans.

Rheumatoid Arthritis

Health exchange plans generally cover most of the immunosuppressant treatments needed to fight rheumatoid arthritis. However due to plan benefit design, this coverage is often subject to very high cost sharing, creating a major access obstacle for many patients.

These treatments are subject to high co-insurance —60% of the time at an average rate of 35%. With this kind of coverage, patients can expect to pay anywhere from $150 to $3,000 for a one-month supply of just one medicine.

Rare Diseases

A rare disease is a condition impacting 200,000 or fewer individuals, such as Huntington’s disease, sickle cell anemia, and Gaucher disease. Collectively, there are about 6,800 known rare diseases that impact as many as 30 million people.

With such small numbers of people affected, treatment options are already limited. Access to treatment becomes even more limited within the exchange plans. A recent study found that, of the eleven medicines used to treat rare diseases reviewed, exchange plans typically place all the medicines analyzed on the highest tier of the formulary, and that’s if the medicine is even covered.