SOURCE: HealthPocket

HealthPocket

December 08, 2015 09:00 ET

Insured Face Rising Out-of-Pocket Charges for Specialty Drugs

Coinsurance Costs Increase up to 20 Percent From First Year of Obamacare

MOUNTAIN VIEW, CA--(Marketwired - Dec 8, 2015) - When comparing average drug out-of-pocket charges in 2016 Affordable Care Act (ACA) plans to the average charges in 2014 ACA plans, a new HealthPocket study found a trend towards higher out-of-pocket costs for those enrollees using expensive drugs within the "specialty" classification. Specialty drugs often treat complex or costly medical conditions and their retail prices may cost up to thousands of dollars per month.

Out-of-pocket charges for specialty drugs after the deductible period come in the form of copayments, which are fixed dollar amounts, or coinsurance fees, which are charges based on a percentage of the drug's overall price. Coinsurance fees, the most common form of cost-sharing for specialty drugs, increased on average for three-out-of-four health plan categories examined (bronze plans, gold plans, and platinum plans). Only silver plans had the same coinsurance fee for specialty drugs in 2014 as they did in 2016. Increases for bronze, gold and platinum health plan categories averaged from 7 percent to 20 percent against their 2014 baseline in the first year of ACA coverage. Practically, these coinsurance charges could cost over $1,000 a month depending on the plan and drug taken. For example, the average specialty drug coinsurance fee for bronze plans in 2016 is 37 percent, which would result in a monthly out-of-pocket cost of $1,307 for the specialty drug Humira ($3,533 retail price estimate). In 2016, the maximum allowable out-of-pocket costs for covered medical benefits in ACA plans is $6,850 for individuals and $13,700 for families.

Copayments, which are less commonly used for specialty drugs, rose more dramatically than coinsurance fees from 2014 to 2016 among ACA plans. The average copayment increased dramatically, ranging from 16 percent to 71 percent depending on the health plan category. Additionally, all four categories of ACA plans had increases in average copayment amounts for specialty drugs.

"While consumers taking specialty drugs represent a small segment of the population, their extreme financial burden combined with the seriousness of their health conditions may result in a public outcry," said Kev Coleman, Head of Research & Data at HealthPocket. "This may motivate pharmaceutical manufacturers, insurers, and the government to collaborate on ways to reduce out-of-pocket costs."

The Centers for Medicare & Medicaid Services reported last month that U.S. spending on drugs increased by 12.2 percent last year and attributed this increase, which was the largest annual increase since 2002, in part to drugs that are typically within the specialty classification. A 2015 study by the AARP Public Policy Institute found that the retail prices for 115 popular specialty drugs surged 10.6 percent from 2012 to 2013.

The full findings as well as the report methodology can be reviewed at "Insurance Out-of-Pocket Charges for Specialty Drugs Increase as Retail Prices Surge."

HealthPocket.com is a free website that compares and ranks all health insurance plans, helping individuals, families, and small businesses to make their best health plan decisions. HealthPocket publishes health insurance market analyses and other consumer advocacy research. HealthPocket's research is nonpartisan and uses only objective data from government, non-profit, and private sources that carry no conditions that might restrict the site from serving as an unbiased resource. HealthPocket, Inc. is independently managed and based in Mountain View, California. Learn more at www.HealthPocket.com.

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