People with Obamacare coverage who take medications for cancer, HIV, multiple sclerosis, and other chronic diseases might pay more out of pocket next year. A greater share of insurance plans sold in the healthcare.gov marketplace will require consumers to pay 30 percent or more of the cost of specialty drugs, according to a new analysis from consultant Avalere Health.
Cost sharing is one of the ways insurers can limit premiums. Patients pay for a greater portion of the medical care they need through deductibles, co-pays, and co-insurance. That last technique splits the bill for medical care, with patients paying a fixed percentage of the total cost and the insurance plan picking up the rest.
Avalere looked at how much cost sharing was required for drugs insurers considered “specialty” medicines. There’s no consistent definition of specialty drugs; the term generally refers to medicine used to treat severe or rare illnesses. The doses can cost thousands of dollars a month. Asking patients to pay 30 percent of that can mean some people skip doses they can’t afford.
Yet the share of silver plans—the most popular tier of Obamacare coverage—that required that level of cost sharing jumped to 41 percent, from 27 percent last year, according to Avalere. The analysis included plans on the federal healthcare.gov marketplace and state exchanges in New York and California; other state-based exchanges were not included.
Difficulty knowing how much medicines will cost is just one of the challenges that make patients poorly equipped to shop for health care. Although their total costs will be capped by plans’ out-of-pocket maximums, the difference between plans with 40 percent cost sharing on expensive drugs and 5 percent could mean thousands of dollars a year. And if you’re diagnosed with cancer in the middle of the year, you can’t switch plans to find one with more generous drug coverage.
The insurance industry has generally defended cost sharing, instead blaming drugmakers for sky-high prices. Last year some patient advocates claimed that insurers were using high cost-sharing arrangements to discriminate against people with costly chronic diseases such as HIV, and at least one insurer changed its pricing in response.
Despite that apparent victory for patients, Avalere’s data suggest more Obamacare enrollees will have to pay more for medication in the year ahead.