Obamacare May Raise Patient Costs for Specialty Drugs

Via Specialty Pharmacy Continuum

According to specialty pharmacy experts, patients who rely on specialty drugs to treat their rare and complex conditions may be forced to pay a large percentage of the drug’s cost instead of a traditional fixed copay, if they are in an Affordable Care Act (ACA) exchange health plan.

Despite some of the exchange plans having the draw of lower monthly premiums, people should prepare themselves for higher deductibles and unpredictable out of pocket costs. Even though the cost structures do vary between the exchange plans, patients may face this issue no matter what exchange plan they are enrolled in.

Avalere examined 603 unique plan designs offered by 60 different carriers in 19 states to assess whether specialty medications are being put in a higher tier with a larger percentage of coinsurance, said Jenna Stento, a senior manager at Avalere. The analysis found that 59% of silver plans on exchanges across the country use coinsurance on the specialty tier instead of a fixed copay. It also found that 23% of silver plans charged coinsurance rates of at least 30% more than the cost of the drugs on the highest formulary tier, and 60% of lower-premium bronze plans apply specialty tier coinsurance greater than 30% of the drug price.

“This examination highlights the fact that patients relying on specialty medications are going to have to lay down significant finances up front until they hit the out-of-pocket cap, which is $6,350 for most people and $2,250 if that person is 200% below the federal poverty rate,” said Ms. Stento. “The fact that patients will be paying an unknown percentage will make it harder for some to plan financially, and will raise questions about access and availability.”

With the number of underinsured and strained patients continuously growing, how can these concerns be corrected?

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