The accessibility of specialty prescription drugs may be as elusive on the Affordable Care Acts health care exchanges as it typically has been off of the exchanges, a fact trusted advisers should be sharing with clients concerned about increasing health care costs and their current plans prescription drug coverage.
More than 60% of silver plans the most purchased plan during open enrollment 2014 place all covered medications for multiple sclerosis, rheumatoid arthritis, Crohns disease and certain cancers in the plans highest formulary tier, according to an analysis of exchange plan benefits for certain medications by health care consultancy Avalere Health. For HIV/AIDS drug therapies, about 25% to 35% of plans place all covered medications on the highest tier. Employer-sponsored and individual health plans also place covered medicines in tiers typically there are four or five of these levels with the lowest tier requiring a low copay ($15 for example) and the highest tiers often requiring a coinsurance of 40% or more.
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While some individuals and employers may be looking to the exchanges for increased cost-sharing for the expensive drugs, the study data shows that may not be the case. Benefit brokers and agents acting as a clients trusted adviser should have an in-depth knowledge of specialty drug coverage on and off the exchanges, as an effort to strategically approach their clients specific health care cost issues.
Specialty medications cost the consumer whether they are on an employers health plan or through the exchange. They have always been expensive with an average cost of $2,000 and greater per month, says Brenda Gagnon, a pharmacy benefit adviser and president and CEO of the health care consulting firm B.M Gagnon Associates.
Whats more, she adds, the costs will continue to climb as additional specialty medications are now coming down the pipeline.
Current estimates for specialty medications are that they will cost an employer 50% to 60% of their total health benefits by 2016, says Gagnon.
Previous studies have also found that higher out-of-pocket costs reduce patients likelihood of taking their prescription medicines to manage chronic conditions, which can also adversely affect health outcomes and increase medical costs in the long run.
The Avalere study commissioned by Pharmaceutical Researchers and Manufacturers of America, known as PhRMA also found that in seven of 19 classes of medicines for serious illnesses, such as cancer, HIV/AIDS, autoimmune diseases such as rheumatoid arthritis and multiple sclerosis and bipolar disorder, more than 20% of silver plans require coinsurance of 40% or more for all drugs in those classes. Similarly, in 10 of the 19 selected classes, at least 20% of silver plans require coinsurance of 30% or greater for drugs in the classes.
Brian Hujdich, executive director of HealthHIV, complains that by placing HIV medications on the top formulary tiers, The plans are restricting access to life-saving treatment, directly countering the intent of meaningful health reform and placing patients at significant risk."
Marcia Boyle, president and founder of the Immune Deficiency Foundation, agrees, saying some insurance companies have found yet another way of penalizing the sickest among us.
One of the promises of the ACA was that an illness wouldn't force people into bankruptcy. The growing trend of prescription coinsurance will gut that promise unless something is done to stop it, she says.
An April report from Avalere Health also found, in almost half of exchange plans, it is difficult or impossible for enrollees to determine what drugs are covered by the plan. Further, 38% of plans had no formulary data available, presenting significant obstacles to consumers, the Washington, D.C.-based group says.
Employers are increasingly seeking transparency on prescription drug pricing and they will be turning to benefit advisers for this information, Gagnon said at the time.
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