Federal, privately insured will pay more out-of-pocket for specialty drugs: 5 findings

Both privately insured Americans and those who buy coverage through government insurance exchanges will likely be faced with increased out-of-pocket costs for "specialty drugs" next year, according to Kaiser Health News' analysis of two studies from consulting firm Avalere Health.

Specialty drugs are used to treat complex, often chronic conditions such as multiple sclerosis, rheumatoid arthritis, hemophilia, some cancers and hepatitis C. Most already require some out-of-pocket payments through current healthcare plans. As the cost of coverage continues to rise, increasing the cost of out-of-pocket payments for such drugs will tighten the financial squeeze many Americans are already struggling to weather. Here are 5 findings on the anticipated rise of individual costs for specialty drugs, and what this will mean for patients with complex conditions, according to KHN.

1. According to KHN, more than half of the bronze plans being sold through federal and state marketplaces now require payments of 30 percent or more of the cost of specialty drugs. This marks a steep rise from last year, where only 38 percent of bronze plans required out-of-pocket payments of this percentage. In the most commonly purchased plans, the silver level plans, 41 percent will require payments of 30 percent or more for specialty drugs beginning January 2015, a 14 percent rise from 2014.

2. Insurers have responded to the rise in the cost of prescription drugs by requiring patients to pay a percentage of their total cost instead of just a flat dollar amount, which is usually significantly less, according to KHN. While insurers say this move will help slow down the rising cost of premiums, Avalere CEO Dan Mendelson said this could make it difficult for patients to afford to stay on medications they need.

3. Citing an earlier Avalere analysis, KHN reported that since the implementation of Medicare's drug program in 2006, all stand-alone drug insurance plans place some drugs into specialty "tiers," and two-thirds of those plans require patients to pay a percentage of the cost of the drugs in the tiers instead of a flat payment. Drugs can only be placed into a specialty category under Medicare plans if the negotiated price of the drug is greater than $600 a month.

4. While there is an out-of-pocket maximum health insurers are allowed to charge patients for specialty drugs, it is often high, usually several thousand dollars, according to KHN.

5. According to the report, while specialty drugs only account for about 1 percent of all prescriptions written, they add up to 25 percent of spending on all drugs, and this amount is expected to rise quickly.

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.

 

Featured Whitepapers

Featured Webinars