Consumers who have complex medical diagnoses that require specialty drugs should carefully examine the health insurance plans offered through the public exchange system to avoid incurring high costs for those drugs. But that task will be complicated by inaccuracies on the public exchange website.
That’s the conclusion of an analysis of public exchange plans by Avalere Health. The study, in which researchers went through all available plans looking for “hidden” drug costs, found that silver plans in particular tend to place such drugs in specialty tiers in their 2015 formularies. Avalere said that 17 percent of silver plans contain two or more specialty drug tiers that will drive up out-of-pocket costs for those patients covered by the plans.
Even consumers who do their homework to try to avoid such costs may still wind up incurring them because of inaccurate data about out-of-pocket costs for drugs that can be found on the federal exchange website HealthCare.gov.
“Avalere conducted a manual search of plan documents for silver plans because of inaccuracies noted on HealthCare.gov and in associated data sets,” Avalere said in a release. “Notably, HealthCare.gov reports formulary cost sharing for all plans in a four-tier structure (including only one specialty tier); however, about 35 percent of silver plans do not use four-tier formularies. Because of this discrepancy, consumer costs appearing on HealthCare.gov may misstate actual enrollee financial responsibility.”
That misinformation on the website could be leading thousands of insured individuals into signing up for plans that cost much more than they believed.
“The mismatch between a plan’s formulary design and the cost-sharing displayed on HealthCare.gov and on state exchange websites may be a source of confusion for consumers,” said Caroline Pearson, vice president at Avalere.
In other words, consumers who gravitate toward silver plans, which have been the most popular to date, may do better financially with a bronze, gold or platinum plan that doesn’t use the specialty drug tiered design, Avalere said.
“Consumers purchasing these plans need to understand what’s in their benefit plan and be ready for a substantial out-of-pocket costs if specialty products are needed,” said Avalere CEO Dan Mendelson. “While these plans are typical of the exchanges and Medicare Part D where insurers are competing to keep premiums low, they remain rare in the employer market.”
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Dan Cook
Dan Cook is a journalist and communications consultant based in Portland, OR. During his journalism career he has been a reporter and editor for a variety of media companies, including American Lawyer Media, BusinessWeek, Newhouse Newspapers, Knight-Ridder, Time Inc., and Reuters. He specializes in health care and insurance related coverage for BenefitsPRO.
