There are some things we know about these formularies.
Under the law, the Obamacare plans benchmarked their drug formularies off of one of the health plans already operating in each state.
In selecting this benchmark, they could have to select from one of four options:
They could choose from: 1) One of the three largest small group plans in the state by enrollment; 2) one of the three largest state employee health plans by enrollment; 3) one of the three largest federal employee health plan options by enrollment; or 4) the largest HMO plan offered in the state’s commercial market by enrollment.
Because there’s a wide variation in the breadth of the drug formularies maintained by these four options, there is also wide variation in the Obamcare plans.
The formulary you’ll get depends most of all on which state you live in (and which benchmark was chosen by the state regulators).
It also appears that the final regulation on all this, issued by the Department of Health and Human Services, gave states some latitude to nix drugs that might otherwise be listed on the benchmark formularies they selected. That regulatory wiggle room seems to undermine the whole idea of having a benchmark plan.
So can you find a good drug plan in Obamacare?
It’s difficult.
But there is a lot of variability.
For example, when it comes to costly, molecularly targeted cancer drugs, some benchmark plans cover 11 drugs, but other plans cover as few as seven. I found one plan in North Carolina that doesn’t cover Actonel for osteoporosis, Aubagio for multiple sclerosis, or Xeljanz for severe rheumatoid arthritis, among other “non formulary” drugs.
In California, a state that Obamacare’s architects are holding up as the model of success, some of the major exchange players—including Anthem, Blue Shield of California and Health Net—have posted their exchange formularies on their websites. Unfortunately, they’re not easy to find — and incomplete.
As another excellent analysis finds, a lack of standardization and on-line tools makes it hard for consumers to compare between plans.
Some of the published lists do not show all of the covered drugs. For instance in California, Blue Shield’s document states that only the most commonly prescribed drugs are shown in its published formulary. Anthem’s published list is also not comprehensive.
Some analysts have tried to look across the plans, but comparisons are as hard for experts to make as they are for consumers.