AIDS advocates say drug coverage in some marketplace plans is inadequate

[Jesus Malverde]

The nation’s new health-care law says insurers can’t turn anyone away, even people who are sick. But some companies, patient advocates say, have found a way to discourage the chronically ill from enrolling in their plans: offer drug coverage too skimpy for those with expensive conditions.

Some plans sold on the online insurance exchanges, for instance, don’t cover key medications for HIV, or they require patients to pay as much as 50 percent of the cost per prescription in co-insurance — sometimes more than $1,000 a month.

“The fear is that they are putting discriminatory plan designs into place to try to deter certain people from enrolling by not covering the medications they need, or putting policies in place that make them jump through hoops to get care,” said John Peller, vice president of policy for the AIDS Foundation of Chicago.

As the details of the benefits offered by the new health-care plans become clear, patients with cancer, multiple sclerosis, rheumatoid arthritis and autoimmune diseases also are raising concerns, said Marc Boutin, executive vice president of the National Health Council, a coalition of advocacy groups for the chronically ill.

“The easiest way [for insurers] to identify a core group of people that is going to cost you a lot of money is to look at the medicines they need and the easiest way to make your plan less appealing is to put limitations on these products,” Boutin said.

http://www.washingtonpost.com/national/health-science/aids-advocates-say-drug-coverage-in-some-marketplace-plans-is-inadequate/2013/12/09/0fca0fd0-5d18-11e3-95c2-13623eb2b0e1_story.html?hpid=z2

[Jesus Malverde]

1. Drug-Cost Surprises Lurk Inside New Health Plans

Americans with chronic illnesses—who are expected to be among the biggest beneficiaries of the health law—face widely varying out-of-pocket drug costs that could be obscured on the new insurance exchanges.

Under the law, patients can't be denied coverage due to existing conditions or charged higher rates than healthier peers. The law also sets an annual out-of-pocket maximum of up to $6,350 for individuals and $12,700 for families, after which insurers pay the full tab.

But depending on the coverage they select, some patients on expensive drug regimens could reach that level fast. Some medications for conditions including hepatitis, rheumatoid arthritis, HIV and cancer can retail for thousands of dollars a month, and some plans require patients to pay as much as 50% of the cost.

The HIV drug Atripla, for example, typically retails for about $2,200 a month. On "silver," or midlevel, plans in Miami-Dade County, Fla., with comparable premiums, monthly out-of-pocket costs for Atripla range from $55 on Molina Marketplace Silver to $902 on Cigna Corp.'s Health Flex 1500. On a single Cigna plan, Health Savings 3400, out-of-pocket costs for Atripla vary from zero if patients buy from an in-network pharmacy to $1,127 if they don't.

http://online.wsj.com/news/articles/SB10001424052702303722104579238263770197936

In a study of 22 carriers in six states, Avalere Health found that 90% of bronze plans (with generally the lowest premiums) require patients to pay a percentage of costs, 40% on average, for drugs in tiers 3 and 4, compared with 29% of employer-sponsored plans that most Americans currently use. Most silver plans also require patients to pay 40% for the highest-tier drugs, although some have flat fees of $70 to $270, the study found.