Obamacare Hikes Cost to Patients of Specialty Drugs for Complex Conditions

Users of “specialty drugs”—high-cost medications
used to treat complex conditions such as multiple sclerosis—are
likely to face a case of sticker shock if they sign up for one of
the Obamacare Exchange health plans. The plans require users to pay
coinsurance, a percentage of medication costs. While that
percentage varies with specific plans and with the “metal” level of
the plan, that’s expected to patients’ out-of-pocket payments
higher than most are acccustomed to paying.

According to Caroline F. Pearson, vice president of the
consulting firm,
Avalere Health:

In most exchange plans, consumers will face paying a percentage
of the costs—known as coinsurance—rather than fixed-dollar
copayments for many specialty medications used to treat rare and
complex diseases.

According to a new Avalere Health analysis, some plans require
enrollees to pay 50 percent of the specialty drug’s cost. …

Specifically, 59 percent of Silver plans on exchanges across the
nation use coinsurance for consumer cost-sharing on the specialty
tier. Among Silver plans, the analysis also found that 23 percent
of plans have coinsurance rates of 30 percent or more on the
highest formulary tier. Sixty percent of lower-premium Bronze plans
apply specialty tier coinsurance greater than 30 percent of the
drug price. By contrast, only 38 percent of Platinum plans require
coinsurance.

What that could mean, specifically, was pointed out by
HealthPocket, which rates health plans. An
article published last summer pointed out, “When compared to
the current individual and family health insurance market, both the
entry-level Bronze Plan and the higher tier Silver Plan will
increase most out-of-pocket drug costs for consumers.” Using
Copaxone, a medication used to treat multiple sclerosis, as an
example of a specialty medication, HealthPocket warned that
“someone on the Bronze plan would have spent the $6,350 annual
limit on out-of-pocket costs by the fourth month of coverage.”

Purchasing a gold or platinum plan can bring medication costs
down, at the cost of higher premiums—and consumers are already
complaining about higher than expected
premiums,
deductibles, and other costs.

Additionally, the Affordable Care Act requires only one drug per
category and class be covered within a health plan formulary, that
drug to be selected by an insurer, and off-formulary medications
aren’t covered at all. That can mean limited options as well as
high costs for consumers who may well have been forced by the law

off a plan that served them better.