Most-costly ACA plans cheapest for specialty drug patients

Individuals with chronic diseases such as multiple sclerosis or cancer will likely spend far less money if they enroll in platinum plans through the exchanges, even though those typically have the highest monthly premiums, according to a new study by researchers at HealthPocket.

That's because out-of-pocket expenses incurred through pharmaceutical costs are often significantly lower on platinum plans, which are designed to cover 90% of medical costs.

The Sunnyvale, Calif.-based research company looked at 2015 rate filings in nine states to generate the data. In most cases those rates still need to be approved by state regulators before they are finalized. Researchers looked at the cost of the most popular specialty drugs used to treat multiple sclerosis, HIV, inflammation, cancer and growth deficiency.

For a 40-year-old on a platinum plan taking one of the specialty drugs, the average premium cost would be $5,918, and the average out-of-pocket limit would be $1,416. That's a total of $7,334. By comparison, the total annual expenses for bronze and silver plans, which have the lowest actuarial value, top $9,000, while the average yearly cost for a gold plan is over $8,000.

In addition, for a 50-year-old taking the cancer drug Gleevec, the average total cost for a platinum plan enrollee is $9,700. That's 15% lower than for bronze plans, 17% lower than for silver plans and 12% lower than for gold plans.

The cost of specialty drugs is an increasingly contentious issue. According to PricewaterhouseCoopers' Health Research Institute, just 4% of patients take such drugs, but they make up 25% of total pharmaceutical costs. In addition, nearly 70% of drugs approved by the FDA last year were specialty drugs. The debate over Sovaldi, the $1,000-per-pill treatment for hepatitis C that is effectively a cure, has recently put the issue in the spotlight.

“The specialty-drug issue is looming quite heavily in the world of insurance,” said Kev Coleman, HealthPocket's head of research and data.

In May, the AIDS Institute and the National Health Law Program filed a complaint with HHS' Office for Civil Rights alleging that four insurers selling plans on the Florida exchange discriminated against individuals infected with HIV. They claim that the drug formularies on some plans make the cost of drugs prohibitively expensive.

Coleman said he wasn't entirely surprised that platinum plans typically proved to be the cheapest option for chronic diseases. “With the Affordable Care Act it's not so much that nothing surprises me anymore,” he said, “but rather I've had enough counterintuitive results that I wait for the data to come in.”

Follow Paul Demko on Twitter: @MHpdemko