The rising out-of-pocket costs for specialty drugs within Affordable Care Act plans is “most concerning,” according to HealthPocket’s report, "In The Fourth Year of Affordable Care Act Coverage, Specialty Drug Out-of-Pocket Costs Remain A Problem For Consumers."
Silver plans, the most commonly purchased ACA plan, saw average coinsurance rates increase by 16 percent in 2017. Enrollees this year pay an average of 36 percent coinsurance on drugs within the specialty tier, compared to 31 percent in 2016. This increase in monthly out-of-pocket costs for the top five specialty drugs ranged from $226.29 to $1,762.59.
The average bronze plan specialty drug cost-sharing rose from 37 percent of the retail price in 2016 to 39 percent in 2017, which is a 5 percent increase. For bronze plans, this increase in monthly out-of-pocket costs for the top five specialty drugs ranged from $90.52 to $705.03.
For gold plans, specialty drug cost-sharing increased an average of 13 percent, with coinsurance expenses rising from 30 percent of the retail price to 34 percent. The 2017 increase in monthly out-of-pocket costs for the top 5 specialty drugs ranged from $181.03 to $1,410.07.
Platinum plans were the only plans whose specialty drug cost-sharing decreased between 2016 and 2017.
“However, inasmuch as only 1 percent of marketplace consumers enrolled in platinum plans for 2017, platinum plans have minor significance to the market as a whole,” the study said.
Cost-sharing obligations within platinum plans declined 11 percent in 2017 compared to 2016. The decrease in monthly out-of-pocket costs for the top five specialty drugs ranged from $181.03 to $1,410.07.
“The increased cost-sharing exacerbates cash flow burdens for enrollees taking specialty drugs until they reach the annual cap on out-of-pocket costs,” the authors write. “However, these caps can be quite high.”
For enrollees within silver plans, the average cap on annual out-of-pocket costs is $6,449 in 2017 for an individual and $12,952 for families. For entry-level bronze plans, the annual caps are even higher: $6,904 for an individual in 2017 and $13,810 for families.
“Specialty drugs continue to attract attention from health care analysts and politicians alike given their staggering costs to consumers and insurers,” the authors write. “The unanswered question for ACA enrollees is whether 2018 will bring any improvements to ACA specialty drug cost-sharing.”
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Katie Kuehner-Hebert
Katie Kuehner-Hebert is a freelance writer based in Running Springs, Calif. She has more than three decades of journalism experience, with particular expertise in employee benefits and other human resource topics.
