Patients taking medicines placed on higher cost-sharing tiers often face serious and chronic health conditions. Increased use of 4 or more tier formularies means patients face higher cost sharing; this also takes the form of coinsurance, or a percentage of costs, which is less predictable for patients. And despite warnings that requiring high cost sharing for all or most medications to treat a condition may be discriminatory, some health plans continue to engage in this practice.
In the commercial market, plans with 4 or more tiers are becoming more common. Twenty-three percent of workers in 2015 were in plans with 4 or more tiers, up from only three percent in 2004. In health insurance exchange plans, 98 percent of silver plans use 4 or more tiers. Beyond the number of tiers, health insurance exchange plan formularies continue to suggest bias against individuals with certain health conditions by placing all medicines to treat certain conditions, such as cancer or multiple sclerosis, on the highest cost-sharing tier.