Health care law's prescription coverages questioned

Specialized drugs, brands are concern

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Some people looking to buy health insurance through the online exchanges set to launch Tuesday are worried the policies might include a poison pill in the form of restrictive prescription drug access, which could make it prohibitively expensive for new enrollees to receive their preferred brand of medicine.

Among the many questions to be answered when the subsidized health plans are unveiled is how comprehensive -- or how minimal -- prescription drug coverage will be, particularly when it comes to brand-name drugs and specialized therapies.

For people with chronic conditions managed by medicine, often the most expensive part of care is not the occasional visit to the doctor's office but the multiple monthly prescriptions that keep their symptoms in check.

Both the cost and breadth of coverage are a concern, said Lisa Nelson, a director of government affairs with the Leukemia and Lymphoma Society.

"Cancer patients [rely] on a lot of innovative products," she said. "The trend has been that these products have been placed on specialty drug tiers ... We see the potential for the trend to accelerate here on the exchanges."

The exchanges -- some operated by states, others by the federal government -- are Web marketplaces where those looking for health insurance will be able to compare policies. Customers who meet certain income requirements will receive subsidies to help offset the price of premiums.

People without insurance are supposed to obtain it or risk a tax penalty.

The exchange is one of the centerpieces of the Affordable Care Act, President Barack Obama's health care overhaul, and all of the policies sold on the exchanges must include drug coverage.

But insurers don't cover the cost of every single drug; instead, they compile "formularies," lists of drugs whose use is approved by a health insurance carrier.

To cut down on the amount of money spent on medicine, insurers try to steer patients and their doctors toward less costly generic drugs, often charging progressively higher co-pays for medicines that are more expensive.

While many drugs can be had for a flat co-payment, the most expensive ones are sometimes cordoned into a "specialty" drug tier, available to patients if they pay a percentage of the cost.

"Requiring patients to pay a high percentage of the costs of the products," Ms. Nelson said, makes it less likely that those with the most serious health issues will be able to afford their medications.

It's not an issue for all patients. Most of the people initially signing up for insurance coverage via the exchanges are uninsured, so whatever prescription coverage they have come Jan. 1, when the new policies first take effect, is bound to be better than what they have now -- nothing.

And policies sold through the exchanges will have caps on out-of-pocket expenses, which, in theory, will prevent prescription costs from getting too high.

The annual cap for policies purchased through the exchanges (and, eventually, for all health policies) is supposed to be $6,350 for an individual and $12,700 for a family policy.

The caps on out-of-pocket costs could be met quickly for those using specialty medications on a percentage-based co-payment plan.

If a cancer therapy costs $10,000 a month and a policy includes a 30 percent co-payment, the drugs could cost $3,000 a month out of pocket, at least until the cap kicks in.

If formularies are too restrictive -- meaning too many medicines are left off -- patients who opt against generic versions of their drugs would bear the whole cost of the brand-name medicine. Those costs wouldn't be subject to the cap, since they were purchased outside the plan.

The issue might be most acute for those who now have insurance coverage and are used to a certain formulary and certain co-pays, but are being forced out of their plans and into the subsidized health insurance exchanges.

That crowd includes people whose companies are shifting them out of employer-sponsored health coverage, as well as those who now have individual policies but whose insurance carrier is dumping those plans in favor of newly designed plans that meet the Jan. 1 requirements of the Affordable Care Act.

Pittsburgh insurer Highmark Inc., for example, recently notified about 38,000 customers that their "guaranteed-issue" policies would be disappearing and that those customers can buy new individual policies through Highmark or via the exchanges.

The opaqueness of the new offerings being unveiled Tuesday is by design -- if one insurer were to leak pricing and coverage information, it would give that insurer a competitive advantage. So insurers are forbidden by the U.S. Department of Health and Human Services from revealing details of their policies.

About the only thing Highmark and the rest of the insurers can say about the prescription coverage they will be selling is that the plans must cover a minimum number of drugs in each treatment category, a benchmark that is ultimately set by the state Insurance Department.

The pharmaceutical industry tried, but failed, to convince the Obama administration and HHS to force health carriers to offer wider access to brand-name drugs on policies offered through the health insurance exchanges.

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Bill Toland: or 412-263-2625.


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