The incidence of plans charging coinsurance greater than 30 percent for specialty medications has increased from 27 percent of Silver plans in 2014 to 41 percent in 2015. Coinsurance is the practice of charging consumers a percentage of the total cost of the medication, as opposed to a set co-payment fee. Approximately two-thirds of exchange enrollees picked Silver plans in 2014.
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.
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. And while people's out of pocket costs go up the administration can claim that premiums moderated.
Health plans continue to focus on managing drug costs to keep premiums low,” said Dan Mendelson, CEO at Avalere Health. “Competitive premiums are key to a sustainable exchange marketplace, which has led plans to pursue more significant cost-sharing. In some cases this could make it difficult for patients to afford and stay on medications.”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.
Overall, 80 percent of Silver plans use coinsurance for consumer cost sharing on the specialty tier. In comparison, 91 percent of Bronze, 80 percent of Gold, and 66 percent of Platinum plans charge coinsurance for specialty medications.
“Coinsurance may make medication costs unpredictable. In addition, changes in cost sharing requirements from year-to-year may surprise some medication-dependent patients,” said Caroline Pearson, vice president at Avalere Health. “As a result, consumers who rely on specialty drugs should make sure they are evaluating their plan options in 2015. In particular, some patients may be better off paying more in monthly premiums in exchange for lower out-of-pocket costs.”
What is not covered in the study is the Medical Device Tax, which is adds to the costs of the such as surgical gloves, dental instruments, coronary stents, artificial knees and hips, defibrillators, cardiac pacemakers, irradiation equipment, advanced imaging technology, and wheelchairs, etc. While the taxes are waged on the manufacturers, those costs are passed along to the consumer, adding to the burden of all patients but especially the chronically ill.