Health and Science

Sticker shock: Obamacare's specialty drug customers faced big price hikes in 2017

Key Points
  • Specialty drug Obamacare plan customers are paying anywhere from $262 to $1,762 more each month for their medications.
  • The higher costs reflect the insurance plans' increase in coinsurance levels.
  • Maximum out-of-pocket limits, and cost-sharing subsidies, can reduce the impact of the hikes for many customers.
Jose Luis Pelaez | Getty Images

Many Obamacare customers who take specialty drugs had to personally pay anywhere from $262 to $1,762 more each month in 2017 than they did last year for those medications, according to a report issued Tuesday.

The report, from the insurance comparison site, found that the average specialty drug coinsurance fee for the most popular type of Obamacare plans rose by five percentage points from 2016.

That increase reflects a trend of insurance plans shifting the burden of directly paying for often-high priced specialty medication onto consumers, according to Kev Coleman, head of data and research for HealthPocket.

And that burden can be heavy.

An Obamacare customer using the arthritis drug Humira, for example, could have seen his out-of-pocket costs for the drug rising from an already steep $1,627.21 per month in 2016 to just below $1,890 per month this year, Coleman's report found.

Customers who use Enbrel, another arthritis drug, faced before and after out-of-pocket costs that closely tracked those who use Humira, the report found.

The report underscored the relatively large change in cost burden on customers of so-called silver individual health plans who use specialty drugs.

About 70 percent of all customers who purchase individual coverage through a government-run Obamacare marketplace are enrolled in silver plans. Those plans pay, on average, 70 percent of all of their customers' health costs, with enrollees being personally responsible for the remaining 30 percent.

However, the exact amount an individual customer personally pays out of pocket — in the form of co-payments, deductibles, or coinsurance — can vary significantly.

While co-payments are flat fees for medical services or drugs, coinsurance charges customers a certain percentage of the costs of those services and drugs.

Coinsurance is also the most commonly used cost-sharing fee for specialty drugs, which account for an estimated $1 out of every $3 spent on prescription medications.

In 2016, the average silver plan's coinsurance fee for specialty drugs was 31 percent of the cost of the drug, HealthPocket's report found.

In 2017, the average silver plan's specialty drug coinsurance fee had grown to 36 percent, the report said.

To quantify the impact of that increase on individuals, Coleman used as examples the five top-selling specialty drugs, which include Humira and Enbrel.

Tecfidera, which treats people with multiple sclerosis, has an average monthly retail cost of $7,101, Health Pocket's report noted.

Silver plan customers of the drug went from personally paying $2,201 per month last year, to more than $2,556 per month this year — a hike of $355 per month in the coinsurance.

Silver plan customers of another MS drug, Copaxone, had increased costs of more than $226 per month, going from almost $1,403 per month in 2016, to $1,629.28 this year.

The biggest increase in dollar terms was seen by people who use Harvoni, a medication that treats hepatitis C.

Harvoni, which is used for 12 weeks, had a monthly average coinsurance cost to silver plan customers of a whopping $12,690 in 2017, which is $1,762.59 higher per month than the cost in 2016.

Coleman noted that Obamacare plans do have maximum limits on how much a customer can be made to pay out of pocket for health services and medication. In 2017, that cap was $6,449 for an individual, and $12,952 for a family.

And significant numbers of Obamacare customers have incomes that are low enough to qualify for discounts in how much they have to pay out of pocket.

But Coleman said that some specialty drug customers, particularly those on fixed incomes, will face "a real struggle" to find extra cash to pay for the higher coinsurance levels identified in HealthPocket's report before they hit their maximum out-of-pocket limit.