VeriStat: How the Top 10 Cost Driving Drugs are Covered in the ACA Market: Part I

This is the first post of a three-post series on this subject.

Which prescription drugs do we spend the most money on as a nation, and how are they covered in the ACA market? In this post, we will explore the coverage of certain cost driving drugs in the individual market.


According to the Express Scripts 2016 Drug Trend report, the prescription drugs in the chart below drive significant aggregate cost based on unit cost as well as utilization. The cost of drugs to an individual is determined by their health plan’s design and drug formulary.  Formularies are lists of prescription drugs that sort each drug into a “tier.”  Typical plan tiers, from least expensive to most expensive, are as follows: generic, preferred brand, non-preferred brand and specialty.


The data science team at Vericred developed a coverage analysis of these ten cost driving drugs in the individual market. We looked at formularies for health plans available to individuals, through or state based insurance exchanges, across the nation to see how each of these drugs is covered. The results show that, for all but Truvada, a majority of individual ACA plans cover these drugs in the specialty tier; the most expensive tier other than not being covered at all. Given the wide variation in coverage, if an individual is taking one of these pricy drugs, shopping around to find a plan that covers it would certainly pay off.


VeriStat-Top 10 Drug Coverage Analysis_Individual


*Coverage tier indicates coverage for at least one drug packaging variant.


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