Accessing Provider Directories and Formularies: CHIR Goes Sleuthing

As we countdown to November 1 and the start of open enrollment, consumers must be able to access a health plan’s provider directory and formulary, or list of covered prescription drugs on an insurer’s website. As we blogged about earlier, new rules require insurers to have the provider directory and health plan’s formulary on their websites without having to create an account or entering a policy number to access the information. In other words, this information should be easily accessible so that consumers can use this information to shop for health plans. A link to the health plan’s formulary must also be included in a health plan’s Summary of Benefits and Coverage (SBC), a consumer-facing tool we’ve described here.

So how accessible is this information right now, less than two weeks away from open enrollment? Well, we decided to put on our Sherlock hat, and went investigating. We decided to look at specific health plans sold in Maryland and California for three main reasons. First, 2016 health plan information is available now for both states. Second, both Maryland and California marketplaces feature a “shop and compare” tool that allows consumers to compare plans. While both tools ask for income, household, and zip code information to direct consumers to plans available in their location, both tools allow consumers to shop anonymously. Consumers don’t have to put in personal information like their name or an email address to use the tool. And third, choosing these states also allowed us to try the shop and compare tools and see how they worked. Using the shop and compare tools, we looked at silver level plans from four insurers with the largest market share in 2015.

The results? Mostly positive regarding the accessibility of provider directories. Of the eight insurer websites we reviewed, provider directories were fairly easy to find. We had specific health plans, but all the websites allowed access to the provider directory even without specific health plan information as long as there was a zip code. Website functions also allow consumers to narrow provider searches by specialty and which providers are accepting new patients. Whether the provider directories are accurate is an area that requires more monitoring, however. Accuracy of provider directories is and has been a consistent concern among consumer advocates.

Our results regarding access to drug formularies are more troubling. This information should be available on all insurer websites and SBCs. In California, this amateur sleuth could only find three formularies from Blue Shield, Anthem, and Kaiser Permanente. Of the available formularies, Blue Shield and Anthem had the updated 2016 list, Kaiser Permanente was from 2015; all three are available as a downloadable document. When searching for the SBCs, only two were found. Where art thou SBCs Anthem Silver 70 HMO and Kaiser Silver 70 HMO? Of the two found, Blue Shield had the link to the webpage where the formulary list could be easily found. The other SBC listed on HealthNet’s website did not have a specific link to the formulary, which incidentally could not be found when I looked.

Things were a little easier in Maryland because the marketplace provides the SBCs as part of its shop and compare tool. Under the rules for 2016 and going forward, insurers must link their formulary list in their SBCs. When reviewing the SBCs for a silver-level metal plan for these insurers, UnitedHealthcare did not have a link to the formulary, only to its website. When searching UnitedHealthcare’s website, the formulary could not be found. Of the remaining SBCs, CareFirst provided the insurer’s website but it does not hyperlink to the actual formulary list. A few clicks later on the CareFirst website, however, and you can access the formulary list. In contrast, however, both Evergreen and Kaiser Permanente had links directly to the formulary webpage for the correct plan. Of the formularies reviewed, however, all were from 2015 and had not been updated for 2016. We’re hoping that these insurers update their formulary lists before open enrollment.

What about the shop and compare tools themselves? Both are helpful with locating available plans at each metal level. They both provide an estimate of the monthly premium cost with and without financial assistance, and both tools showcase specific plan information like the SBC in Maryland to help consumers shop and compare. While California’s tool does not link to each plan’s SBC, it does have a standardized summary outlining 13 key benefits such as primary care, specialty care, urgent care, lab testing, etc. and the applicable cost sharing. The key plan benefits summary also includes the individual and family deductibles and out-of-pocket spending. As this is a one-page form that pops up when clicking on plan details, it may be easier for consumer to make an apples-to-apples comparison since this document does not have be downloaded and opened like the SBCs on Maryland’s website.

A provider look-up tool and a feature designed to assess whether a drug is covered under a particular health plan are also scheduled to be available on the federally facilitated marketplaces this year according to CMS. A recent AP story, however, indicates that these tools may not be ready to use by the start of open enrollment. We’ll be sure to keep this on our radar as to when these tools are available.

One last consumer assister tool that we want to mention, available in all states, are the navigators, insurance brokers and consumer assisters who can help walk new and enrolled consumers alike through the enrollment process. These assisters are available to help find important information like a provider directory or formulary and to answer questions about the enrollment process. While some new tools may be available this year, assisters can provide face-to-face time and a human touch. For the federally facilitated marketplace, consumers can find them through the “Find Local Help” link on

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.