speaker: jane horvath september 11, 2014

A Review of Behavioral Health Benefits in Newly Reformed Individual Marketplaces- Services and Drug Coverage

Sponsored by

Produced bySpeaker: JANE HORVATH

September 11, 2014

Section IA comparison of behavioral and physical health benefits as well as provider networks in Bronze and Silver plans in five states.

Section IIAn analysis of drug coverage, utilization management, and cost-sharing for 25 products in nine states.

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

SEC

TIO

N I

BEHAVIORAL HEALTH BENEFITS AND PROVIDER NETWORKS

• 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?

SECTION I:

STUDY QUESTIONS

4BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS

• 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 cost-sharing

• 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.

SECTION I:

METHODOLOGY

5

*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.BEHAVIORAL HEALTH BENEFIT AND

PROVIDER COMPARISONS

Findings:BEHAVIORAL HEALTH SERVICE ATTRIBUTES

No clear distinctions in services/cost sharing between metal levels or states.

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

BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 6

Findings:BEHAVIORAL HEALTH PROVIDER NETWORKS

This research is not sufficient to evaluate network adequacy. All these plans meet federal requirements for adequacy.

Nearly all plans included coverage for non-physician 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.

BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS 7

BEHAVIORAL HEALTH BENEFIT AND PROVIDER COMPARISONS

Summary:BEHAVIORAL HEALTH PROVIDER NETWORKS

With all the caveats about data quality and sample size;

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.

8


> MORE PSYCHIATRISTS THAN ONCOLOGISTS= BEHAVIORAL HEALTH AND PHYSICAL HEALTH COST-SHARING IS THE SAME< LESS PSYCHIATRISTS THAN ONCOLOGISTSX NO INFORMATION* THESE NUMBERS DO NOT TAKE INTO ACCOUNT PROVIDERS LISTED AT MULTIPLE LOCATIONS. MAY OR MAY NOT INCLUDE PSYCHIATRISTS.

COMPARING BEHAVIORAL AND PHYSICAL HEALTH BENEFITS AND PROVIDER NETWORKS

State Plan

Inpatient, In-Network Cost-Sharing

Behavioral Health vs. Physical Health

Outpatient, Out-of-Network Cost-Sharing Behavioral Health vs.

Physical Health

Psychiatrists vs. Oncologists

Overall Number of Behavioral Health Providers*

Arizona

Humana Connect 6300/6300 Bronze = = < 592 BCBS Everyday Health Alliance 6000 Bronze = = > 7

Humana Connect Silver = = > 589

BCBS Everyday Health Alliance 4000 Silver = = > 7

Illinois

Blue PPO Bronze 006 = = > 0

Humana Connect Bronze 6300/6300 = = > 1346

Blue Choice Silver PPO 003 = = > 0

Humana Connect Silver 4600/6300 = = < 1346

Montana

Access Care Bronze = = < 5

SmartHealth Value Bronze 3000 = = > 189 PacificSource: SmartHealth Value Silver 3000 = = > 190 Connected Care Silver: Montana Health

Cooperative = = < 4

New Jersey

AmeriHealth NJ Tier 1 Advantage – Bronze EPO = X < 22

Horizon Advantage EPO Bronze = = > 45

Horizon Advance EPO Silver = = > 45

AmeriHealth NJ Tier 1 Advantage – Silver EPO H.S.A. = X < 22

Texas

Blue Advantage Bronze HMO 005 = = > 399

Blue Advantage Bronze HMO 006 = = > 399

Molina Marketplace Silver Plan = = < 21

Blue Advantage Silver HMO 003 = = > 399

• 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

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

10

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.

In two states, Texas and Illinois, Silver plans had higher cost sharing than Bronze plans—for both inpatient and outpatient coverage.

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.


11

FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPY COVERAGE

SEC

TIO

N I

I

• 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.

• Plans included were selected on the basis of largest enrollment or plans in the most populous region of a state.

• Where coverage varied based on dosage form or strength, Breakaway captured information on the form/strength with the least access restrictions.

• 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)

ProductsAbilifyBrintellixCelexaClozarilCymbaltaEfexorFetzimaGeodonInvegaLatudaLexapro

PaxilPristiqProzacRisperdalSaphrisSavellaSeroquelViibrydZoloftZyprexa Depakote

LamictalLithaneTegetrol

FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES

SECTION II:METHODOLOGY

13

States ReviewedArizona CaliforniaColorado IllinoisMarylandMontanaNew JerseyNew YorkTexas

AVERAGE COVERAGE RATES WITHIN STATES

The average frequency of coverage for 25 products among 8 plans in each the 9 states.

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.


Arizona

Californ

ia

ColoradoIlli

nois

Montana

Maryland

New Jerse

y

New YorkTexa

s0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

87%

62% 62%

95%

84% 83%79%

75%79%

Average Coverage Rates of All 25 Behavioral Health Therapies Within Each State

14

N= 8 plans/state

Arizona California Colorado Illinois Montana Maryland New Jersey

New York Texas0%

10%20%30%40%50%60%70%80%90%

100%90%

60% 61%

93%84% 84% 82%

62%

85%84%

64% 62%

96%

84% 81%76%

88%

73%

Average Coverage Rates Across States by Metal Tier

Bronze Silver

State

Perc

ent o

f Dru

g Li

sts/

Form

ular

ies

AVERAGE COVERAGE RATES WITHIN STATESBY METAL LEVEL

15

Branded Generic0%

10%20%30%40%50%60%70%80%90%

100%

50%

6%

50%

94%

Average Coverage Rates of Branded and Generic Products

No Yes

Perc

ent o

f Dru

g Li

sts/

Form

ular

ies

AVERAGE COVERAGE RATES OF BRANDED VS. GENERIC THERAPIES

Includes all drugs in all plans across all 9 states.

16

BRANDED COVERAGE FINDINGS

9 branded productsAbilifyBrintellixFetzimaInvegaLatudaPristiq SaphrisSavellaViibryd

• 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” BY PLAN TYPE

Count of covered products by tier across all 72 plans and across all 9 states.


Tier 1 Tier 2 Tier 3 Tier 4 Plan Does Not Specify

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

48%

13%

23%

6%9%

63%

8%

28%

0% 1%

61%

11%

20%

6%3%

65%

9%

22%

2% 0%

Tiering Clusters of All Covered Products by Plan Type

HMO PPO EPO POS

Perc

ent o

f Dru

g Li

sts/

Form

ular

ies

18

• 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

TIERING “CLUSTERS” BY METAL LEVEL

Count of covered products across all 72 plans across all 9 states

• 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


Tier 1 Tier 2 Tier 3 Tier 4 Plan Does Not Specify

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

53%

12%

23%

4% 8%

61%

9%

28%

2% 1%

Tiering Averages of All Covered Products by Metal Level

Bronze Silver

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

19

TIERING “CLUSTERS” BY STATE

Count of covered products across all 72 plans across all 9 states


Tier 1 Tier 2 Tier 3 Tier 4 Plan Does Not Specify0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

53%

6%

27%

2%

12%

59%

12%

28%

1%0%

63%

27%

7%

0%1%

57%

2%

29%

1%

12%

70%

10%

19%

0% 0%

59%

11%

21%

9%

0%

77%

5%

9%

0%

9%

59%

15%

26%

0% 0%

51%

12%

23%

14%

0%

Tiering Clusters of All Covered Products By State

Arizona California Colorado Illinois Montana MarylandNew Jersey New York Texas

Tier

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

20

FINDINGSCOST SHARING


OVERVIEW OF FINDINGS

• 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

21

AVERAGE PRESCRIPTION-ONLY DEDUCTIBLESBY STATE


Arizona California Illinois Maryland Overall $-

$200

$400

$600

$800

$1,000

$1,200

$1,400

$730

$250

$1,167$1,000

$778

Average Rx-Only Deductible Across States

StateAv

erag

e Rx

Ded

uctib

le

• 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 PRESCRIPTION-ONLY DEDUCTIBLESBY METAL LEVEL


Bronze Silver Overall $-

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600 $1,500

$698 $778

Average Rx-Only Deductible by Metal Level

Metal Level

Aver

age

Rx D

educ

tible

23

• Among the 4 states using a prescription-only deductible

COST-SHARING IN PLANS WHERE RX EXEMPT FROM ANY DEDUCTIBLEBY METAL LEVEL

Average copays by metal level across all states and among all plans that exempt Rx from any deductible.

Only includes plans that specify a copay amount.

FORMULARY REVIEW OF BEHAVIORAL HEALTH THERAPIES 24

Bronze Silver $- $5

$10 $15 $20 $25 $30 $35

$28 $30

Average Copay in Plans Where Rx Exempt From Combined Deductible

Metal Level

Dol

lars

AVERAGE COST-SHARING WHEN DRUGS APPLY TO DEDUCTIBLEBY METAL LEVEL

Average cost-sharing among all plans and across all states

Only includes plans that specified a cost-sharing value greater than $0 or 0%

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


Bronze Silver $-

$5

$10

$15

$20

$25

$30

$35 $30

$17

Average Copay Before Deductible is Met

Metal Level

Dol

lars

Bronze Silver0%

10%20%30%40%50%60%70%80%90%

100%100% 100%

Average Coinsurance Before Deductible is Met

Metal Level

Perc

ent

AVERAGE COST-SHARING WHEN DRUGS APPLY TO DEDUCTIBLEBY METAL LEVEL

Average cost-sharing among all plans and across all states

Only includes plans that specified a cost-sharing value

Top chart is average copay after any deductible is met by metal level

Lower chart is average coinsurance after any deductible is met by metal level


Bronze Silver $- $2 $4 $6 $8

$10 $12 $14 $16 $14

$3

Average Copay After Deductible is Met

Metal Level

Dol

lars

Bronze Silver0%

10%20%30%40%50%60%70%80%90%

100%

23%11%

Average Coinsurance After Deductible is Met

Metal Level

Perc

ent

Abilify

Brintellix

Celexa

Clozaril

Cymbalt

a

Depak

oteEfe

xor

Fetzi

ma

Invega

Lamict

al

Latu

da

Lexa

pro

Lithan

ePax

il

Pristiq

Proza

c

Risperd

al

Saphris

Savell

a

Sero

quel

Tegetr

ol

Viibryd

Zeldox

Zoloft

Zyprexa

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

76%

100%

41%35%

77%

0%

31%

100%

81%

0%

81%

31%

0%

31%

81%

36%

52%

80%

57%62%

0%

81%

67%

31%

54%

Utilization Management Rate Among HMO Plans

Product

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

AVERAGE UTILIZATION MANAGEMENTBY PLAN TYPE

Key takeaway:

Slightly higher application of UM in HMO plans with a similar, though less frequent, pattern across drugs among PPO plans


Branded Generic

23

Abilify

Brintellix

Celexa

Clozaril

Cymbalt

a

Depak

oteEfe

xor

Fetzi

ma

Invega

Lamict

al

Latu

da

Lexa

pro

Lithan

ePax

il

Pristiq

Proza

c

Risperd

al

Saphris

Savell

a

Sero

quel

Tegetr

ol

Viibryd

Zeldox

Zoloft

Zyprexa

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

78%

86%

21%26%

43%

4%8%

100%94%

0%

89%

13%

0%

13%

69%

8%

29%

94%

56%

29%

0%

94%

38%

4%

38%

Utilization Management Rate Among PPO Plans

Product

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

Branded

AVERAGE RATE OF UTILIZATION MANAGEMENT BY STATE AND TYPE OF UMKey takeaways:

Quantity limits most common UM approach

Step therapy is a significant UM approach


Arizona

Californ

ia

ColoradoIlli

nois

Montana

Maryland

New Jerse

y

New YorkTexa

s0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

52%

37% 36%

50%

12%

37%

5%8%

42%

10%

16%

1%

20% 21%

3%

0%

17% 16%15%13%

1%

10%

3% 3%

18%

4%0%

Rates of Utilization Management Type of UM By State

Quantity Limits Step Therapy Prior Authorization

State

Perc

ent o

f Dru

g Li

sts/

Form

ular

ies

28

KEY FORMULARY TAKEAWAYS

Few differences in cost-sharing between Bronze and Silver plans

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 Marketplaces- Services and Drug Coverage

Sponsored by

Produced bySpeaker: JANE HORVATH

September 11, 2014

COVERAGE RATES OF EACH DRUG BY STATE

AP

PEN

DIX


Abilify

Brintellix

Celexa

Clozaril

Cymbalta

Depakote

Efexor

Fetzi

ma

Invega

Lamict

al

Latuda

Lexa

pro

Lithane

Paxil

Pristiq

Proza

c

Risperd

al

Saphris

Save

lla

Sero

quel

Tegetrol

Viibryd

Zeldox

Zoloft

Zypre

xa

Avera

ge0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 0%

100%

75%

100%

75%

100%

0% 0%

100%

0%

100%

75%

100%

50%

100%100%

0% 0%

100%

75%

0%

100%100%

75%

61%

0% 0% 0% 0% 0% 0% 0% 0%

62%

Coverage Rate Among 8 Colorado Plans by Metal Level

Bronze Silver

Product

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

Branded


Abilify

Brintellix

Celexa

Clozaril

Cymbalta

Depakote

Efexor

Fetzi

ma

Invega

Lamict

al

Latuda

Lexa

pro

Lithane

Paxil

Pristiq

Proza

c

Risperd

al

Saphris

Save

lla

Sero

quel

Tegetrol

Viibryd

Zeldox

Zoloft

Zypre

xa

Avera

ge0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%

25%

100% 100%

75%

100% 100%

25%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

93%

50%

100%

50%

96%

Coverage Rate Among 8 Illinois Plans by Metal Level

Bronze Silver

Product

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

Branded


Abilify

Brintellix

Celexa

Clozaril

Cymbalta

Depakote

Efexor

Fetzi

ma

Invega

Lamict

al

Latuda

Lexa

pro

Lithane

Paxil

Pristiq

Proza

c

Risperd

al

Saphris

Save

lla

Sero

quel

Tegetrol

Viibryd

Zeldox

Zoloft

Zypre

xa

Avera

ge0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%

0%

100% 100%

75%

100%

0%

75%

100% 100%

0%

100% 100%

75%

100%

75%

100%

75%

100% 100% 100% 100% 100%

75%

82%

50% 50%

100%

50% 50% 50% 50%

0% 0% 0%

100%

76%

Coverage Rate Among All 8 New Jersey Plans by Metal Level

Bronze Silver

Product

Perc

ent o

f Dru

g Lis

ts/F

orm

ular

ies

Branded

speaker: jane horvath september 11, 2014

Documents

behavioral health cost

behavioral health services

physical health benefits

mental health parity

provider location

provider comparisonscompared

accessbh provider

countable provider