Observations on Drug Formulary Structures

Research into drug coverage under the Affordable Care Act has uncovered certain drug classification exemptions.

The Issue

This analysis uses HIX Compare data and looks at the use of tier 2 for generic drugs and the designation of certain drugs as “wellness” drugs which are then exempt from the plan deductible or have other exceptional cost-sharing rules outside the plan’s regular formulary cost sharing.

Key Findings

  • There is a great deal of variation among plans and markets as to whether generics are always located on tier 1.

  • For 2015, seven of the 14 state-based exchange states (CA, CT, DC, HI, NM, NY, and VT) do not have any silver level exchange plans that specify a non-preferred generic tier.


These plan designs for drug coverage have the potential to be very important to consumers and the health care system overall.


About the grantee

Breakaway Policy Strategies provides research, analysis, practical advice and strategic solutions to guide stakeholders in navigating the transformative changes taking place in the American health care system.

Featured Collection

Health Reform: By The Numbers

Timely data and analysis on key issues related to Affordable Care Act (ACA) coverage expansion and ACA implementation and impact.

Browse this collection