HealthPocket recently analyzed certain individual health plans available for 2015 under the Affordable Care Act and found that platinum plans — which generally have the highest premiums — actually represent the best buy for consumers who need to use expensive specialty drugs.
Although the study focused on individual health plans, consumers who are covered through their workplace face similar calculations if they have more than one plan to choose from, Coleman said.
Many companies hold their annual open enrollment period in the fall, often in October and November. Open enrollment for individual plans under the Affordable Care Act, also known as Obamacare, is scheduled to start November 15 for coverage beginning January 1, 2015.
HealthPocket’s analysis found that, on average, consumers taking one of the five specialty drugs would incur the lowest total costs in a higher-premium platinum plan. A 50-year-old consumer taking Gleevec, for example, incurred annual costs of approximately $11,400 on average in bronze plans, including both annual out-of-pocket costs and premiums. That same individual incurred an average total cost of about $9,700 in platinum plans, even though the plan’s premiums were more than $3,000 more expensive for the year than bronze-plan premiums.
That’s because, while the premium price is the dollar figure displayed most prominently when consumers shop for health plans, this monthly charge makes up only part a consumer’s total health care spending. There are also deductibles, or the amount a consumer has to pay before insurance kicks in; copayments, or the fixed amount paid to the health care provider, usually at the time of service; and coinsurance, which is the percentage of the medical bill the consumer is responsible for.
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Different plans have varying levels of coverage for these cost-sharing charges. A platinum plan might require a $10 copayment for a doctor’s visit, while a lower-premium bronze plan might require $40, for example. (Coverage also varies to some degree within the same metal tier, so consumers shouldn’t assume that all platinum plans have the same exact coverage package.)
Comparing Plans’ Out-of-Pocket Cap
While cost-sharing charges affect a consumer’s total health-care outlay, they’re not the biggest factor driving annual spending for those on specialty drugs, Coleman said. Instead, the insurance plans’ “out-of-pocket maximum” wields the biggest influence on the wallet. This refers to the cap on the policyholder’s annual out-of-pocket costs, including all copayments, coinsurance and drugs covered by the plan, but excluding premium costs.
Platinum plans have much lower out-of-pocket maximums on average than the other metal tiers — $1,417 for platinum versus $6,386 for bronze, $5,745 for silver, and $4,230 for gold, according to the HealthPocket analysis. Once a consumer hits that amount, she incurs no additional costs for drugs or services, as long as she sticks within her plan’s provider network and to her plan’s covered drug list. In the study, premiums accounted for the entire difference between the $9,700 in total spending for the 50-year-old taking Gleevec on a platinum plan and the plan’s $1,417 out-of-pocket spending limit.
Consumers in platinum plans hit their annual out-of-pocket maximum, and thus become fully covered, faster than those on other metal-tier plans. This is why those on specialty drugs incur lower total costs despite paying higher premiums.
Those taking very expensive drugs will likely hit their out-of-pocket maximum each year, Coleman said. This means there’s an easy way to calculate their annual medical expenses: add the plan’s out-of-pocket maximum to the monthly premium cost times 12. Comparing that total will give consumers a more accurate picture of plans’ coverage—and their likely annual spending total—than comparing on premium price alone.
Verifying Drug Coverage and Restrictions
All Obamacare health plans must include some prescription drug coverage, but that doesn’t mean they have to cover all drugs on the marketplace. If a drug isn’t included in a health plan’s “formulary,” as its coverage list is called, then there are no limits on annual out-of-pocket costs related to that drug—and, with some exceptions, patients are responsible for the full cost of drugs not on the formulary list.
That’s why it’s very important for consumers to verify each year that their plan covers the drugs they’re taking. Even those already enrolled in a plan they want to renew for next year should double check that the coverage list won’t be changing for 2015, experts say.
Check into Drug Restrictions
It’s not enough to ask the plan, “Do you cover Lipitor?” for example. Consumers also must also check to see if there any restrictions on that coverage, Coleman said.
Health plans restrict drug coverage in three ways:
1) limiting the allowed monthly dosage
2) requiring prior authorization from the insurer to take the medication
3) requiring “step therapy,” which means that patients must try a series of other (usually less expensive) drugs before the desired medication and then get a doctor to say those earlier drugs didn’t work
This last step can prove particularly onerous for patients on multiple medications that manage multiple chronic conditions. Someone who has, through trial and error with a doctor, figured out the right combination of drugs might not want to disrupt that balance to save a few hundred dollars a year on a cheaper health plan.
Bottom line? Do the math and make some phone calls. It’s not fun stuff, but some homework is necessary to prevent unpleasant surprises during the year.
“Back when people imagined the Affordable Care Act, they thought, ‘we’ll boil it down to metal tiers and make it simple for people,’” Coleman said. “But our research shows that hasn’t necessarily been the case.”