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Drug cost-sharing to be higher in ACA Bronze, Silver plans

An analysis from HealthPocket has found that consumers who choose lower cost Bronze and Silver plans under the Affordable Care Act will likely pay more for prescription drugs than they do now.

Compared to similar existing individual and family plan co-pays and co-insurance costs, prescription drug coverage will cost consumers an average of 34 percent more out of pocket for these medications if trends continue, HealthPocket said in a recent news release about its analysis of early health insurance rate filings. 

In the current individual and family health insurance market, one out of five health plans do not include prescription drug coverage, the report said.

On the positive side, the ACA will eliminate any exclusion of drug coverage by requiring it as an essential health benefit in all health plans. But what consumers in most instances pay out-of-pocket for those drugs is likely to increase substantially from the current average annual per capita expenditure of $758, according to HealthPocket.

Importantly, drugs not covered by a specific health plan are not subject to any out-of-pocket limits, so checking to make sure a particular medication is included within the drug benefit is key to selecting the right plan, the report said.

Consumers deciding on healthcare plans offered on health insurance exchanges should pay close attention to what plans offer to minimize out-of-pocket increases for medications, said Kev Coleman, head of Research & Data at HealthPocket and author of the study. "When it comes to drug costs and changes in our newly reformed health care system, the fine print really matters," he said in the release.

While these rate filings did not include formularies – the list of covered medications within each plan – many of them did include information regarding how much health plan members will pay for various categories of covered drugs: generics, preferred brand name drugs, non-preferred brand name drugs, and expensive specialty drugs.

The analysis also found that the higher the premium cost of the health plan category under the ACA, the lower the drug costs. In most cases, the higher-end Gold and Platinum plans had an average lower drug cost-sharing than the averages for comparable existing plans.

However, the less expensive Bronze and Silver plans, with higher out-of- pocket drug costs, are expected to be the most popular for cost-conscious consumers.

For example, the average generic co-pay under current health plans is $11.72; for new Bronze health plans, $20.24; and for new Silver health plans, $13.44, the report said.

In addition, consumers with complex conditions needing specialty drugs--higher cost medications that are typically injected--need to be aware of what their cost-sharing obligations will be under each metal plan as coinsurance rates for these medications vary widely, the release said.

Higher out-of-pocket costs for drugs may drive some enrollees to explore lower cost 90-day mail order supplies for those medications they use regularly or pharmacy-based drug discount programs, the report noted. Drug purchases through these pharmacy-based drug discount programs typically are not counted against the health plan's annual limit on out-of-pocket spending. These discount drug programs can be very affordable and are available at major pharmacy chains.

HealthPocket's analysis was based on rate filings for 2014 qualified health plans in California, Connecticut, Ohio, Oregon, Rhode Island, Washington, and Vermont.

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