Abstract 12678: Marketplace Plan Designs for Cardiometabolic Therapies in Rural and Urban Counties in the US

Abstract

Introduction: In the US, important variation exists in cardiovascular risk factor burden and rates of death across rural and urban counties. Affordability and non-financial mechanisms can present as barriers to treatment, yet little is known about if there may be systematic variation in plan design by rural and urban settings. We assessed whether rural or urban county type is associated with insurance plan design for sacubitril/valsartan, dapagliflozin, and empagliflozin. Methods: We evaluated the median premium silver-level plan from 26 selected states with federally-facilitated marketplaces based on the Bureau of Economic Analysis Regions. We then examined features such as coverage, tier, copay or coinsurance, expected out-of-pocket costs for 30 day supply, and coverage contingent non-financial elements including prior authorization, step therapy, and quantity limits. Logistic regression models, stratified by medication and state, assessed if rural/urban county type was a predictor of cost-sharing mechanism, coverage contingent elements, or out-of-pocket costs. Results: The mean population of urban and rural counties was 1.2M (±1.3M) and 19,364 (± 40,006), respectively. Urban counties had a higher proportion of Black/Hispanic individuals (31% vs. 16%) and higher median household incomes ($65,835 ± $17,452 vs. $47,212 ± $10,549); all P < 0.01. Over 90% of plans covered each of the three medications, irrespective of rural/urban county type. Across each of the three medications and states, plans in urban counties had higher odds of including prior authorization (OR: 10.59; 95% CI: 2.55-43.96; P = 0.001) and use of coinsurance (OR: 9.06; 95% CI: 2.55-32.20; P = 0.001) compared with plans in rural counties. For each drug, predicted out-of-pocket costs differed as much as $250 between rural and urban counties for a given state. Conclusion: Most plans cover these newer cardiometabolic therapies across sampled US counties, but there was substantial variation in plan architecture across counties with greater utilization of prior authorization and coinsurance as a cost-sharing mechanism in urban counties. Given a greater population density, these mechanisms may guard against moral hazard and overutilization in urban settings.