Study: Obamacare Out-of-Pocket Charges for High-Cost Specialty Drugs Escalate in 2017

Silver plans saw a 16% increase insurance out-of-pocket obligations for specialty drugs this year

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Sep 05, 2017, 08:00 ET

MOUNTAIN VIEW, Calif., Sept. 5, 2017 /PRNewswire-USNewswire/ -- Today HealthPocket^® released the results of a comprehensive investigation of drug cost-sharing within Affordable Care Act (ACA) health plans. Given that specialty drugs account for more than one of every three medication dollars spent, HealthPocket gave special attention to expenses associated with this class of drugs. Specialty drugs are very expensive medications whose course of treatment can cost in the thousands or tens of thousands of dollars. For example, the retail price of the specialty drug Humira (which is used to treat various inflammatory conditions) is over $5,000 a month.

HealthPocket found that the standard cost-sharing mechanism for specialty drugs is a coinsurance fee where the insured pays a percentage of the total price of the specialty drug. When comparing this year's coinsurance fees for specialty drugs to last year's fees, HealthPocket found:

Silver plans, the most commonly purchased ACA plan, increased its average coinsurance rate by 16 percent in 2017
Entry-level bronze plans had their coinsurance fees increase 5 percent
Gold plan coinsurance fees increased 13 percent

When utilizing the retail prices for each of the top five specialty drugs, HealthPocket found that the 16 percent increase in silver plan coinsurance rates would produce $226 to $1,763 more in monthly out-of-pocket costs in 2017.

Platinum plans were a bright spot within the data, being the only category of ACA plan whose specialty drug cost-sharing decreased in 2017 compared to the prior year. However, inasmuch as only 1 percent of marketplace consumers enrolled in platinum plans for 2017, platinum plans have minor significance to the market as a whole.

Yearly caps on out-of-pocket costs remain very high in 2017 for most ACA plans. The average limit on annual out-of-pocket costs for silver plans is over $6,000 for individual coverage and nearly $13,000 for family coverage.

The full findings as well as the report methodology can be reviewed at "In The Fourth Year of Affordable Care Act Coverage, Specialty Drug Out-of-Pocket Costs Remain A Problem For Consumers."

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.

SOURCE HealthPocket