Out-of-Pocket Costs for Specialty Drugs Increasing for Exchange Plans in 2015

Patients on exchange plans are more likely to see higher out-of-pocket costs for their specialty drugs in 2015 compared with 2014, according to a new analysis from Avalere Health.

Plans charging coinsurance greater than 30% for specialty medications for life-threatening illnesses such as cancer, rheumatoid arthritis, or multiple sclerosis, has increased to 41% of silver plans in 2015 from just 27% in 2014. Overall, approximately two-thirds of individuals on the exchanges picked silver plans in 2014 and 28% of exchange enrollees are between the ages of 18 and 34 years.

“Health plans continue to focus on managing drug costs to keep premiums low,” Dan Mendelson, chief executive officer at Avalere Health, said in a statement. “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.”

More than half (52%) of bronze plans are charging a coinsurance above 30% for specialty tier drugs in 2015 (up from 38% in 2014), while 26% of platinum plans are doing so (up from 17% in 2014). Gold plans are the least likely to be picked.

A total of 80% of silver plans, 91% of bronze plans, 80% of gold, and 66% of platinum plans charge any coinsurance for cost sharing on the specialty tier, Avalere reported. Overall, 63% of plans use coinsurance for specialty drugs.

According to Caroline Pearson, vice president at Avalere, coinsurance can make medication costs unpredictable for consumers, and from year to year the changes in cost-sharing requirements can surprise patients who are medication depedent.

“As a result, consumers who rely on specialty drugs should make sure they are evaluating their plan options in 2015,” she said. “In particular, some patients may be better off paying more in monthly premiums in exchange for lower out-of-pocket costs.”