By KATIE THOMAS
The New York Times
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Among the most troubling questions facing consumers as they shop for insurance under the Obama administration's new health-care law is whether the plans will cover the drugs they take — and how much they will have to pay for them.
But with less than two weeks remaining until enrollment opens Oct. 1, the answers are still elusive and anxiety is growing for consumers whose well-being depends on expensive medications.
States running the marketplaces where the plans will be offered have not released details about which drugs will be covered. Insurers have said little about how much consumers will be asked to contribute or what types of restrictions will be placed on certain medicines. Of the few states that have revealed specifics, some plans will require patients to contribute as much as half of the cost of the most expensive drugs.
“I've got to be honest and say I'm a little bit nervous,” said Jessica Thomas, a mental-health counselor in North Carolina who takes the drug Tecfidera to treat her multiple sclerosis.
Thomas, 34, has been enrolled for two years in a program for people with expensive medical conditions that is run by the state of North Carolina. But that program is ending in December, and she must select a new plan in the state marketplace. At the top of her mind is how much she will have to pay for Tecfidera, which costs more than $4,000 a month. “I think that's the hard thing right now is that it's the unknown, deciding what the financial cost will be,” she said.
The picture will not get immediately clearer once enrollment begins. Without a central hub for evaluating drug coverage, patient-advocacy groups say they are already warning their members to prepare for a tedious slog through websites, downloaded records and phone calls to customer-service hotlines.
Insurers and officials in the Obama administration say that consumers will have six months, once enrollment opens, to choose a plan that's right for them.
The plans offered in the marketplaces must cover a minimum number of drugs in every treatment category, with the exact count set by a representative commercial plan, known as a benchmark plan, that is designated in each state.
Oregon, Virginia, Connecticut and other states plan to cover more than 97 percent of drugs, while others like Maryland, Colorado and California plan to cover from 54 to 84 percent, according to an analysis by Avalere Health, a consulting firm. Patients can lobby for an exception if they can demonstrate that a drug not covered by their plan is medically necessary.
But how many drugs will be offered under the plans is only a starting point. Perhaps more significant is how much patients will be asked to contribute toward the cost of those drugs. Only a handful of states have released those details, but advocates for patients with chronic diseases and those in the drug industry say they are troubled by what they have seen so far.
Many of the plans are requiring that patients taking the most expensive specialty drugs — those for treating serious illnesses like cancer, multiple sclerosis and autoimmune disorders — contribute significantly to the cost. For example, in Oregon, among the dozens of plans expected to be offered are standard plans that will ask consumers to pay half the cost of specialty drugs.
In Washington, plans offered by insurance carriers in the state exchange vary in the amount those insured would be required to pay for such drugs, starting from half on downward.
Requiring consumers to share in the rising cost of specialty drugs is not new, but Caroline Pearson, a vice president at Avalere, said the practice appeared to be more prevalent in the plans offered in the state marketplaces, and consumers will be asked to pay more. A recent survey by the Kaiser Family Foundation of employer health plans found that the current average contribution was 32 percent for specialty drugs.
The health-care law limits the amount that a patient is required to pay out of pocket to $6,350 a year for an individual and $12,700 for a family, a welcome change for some patients previously required to pay tens of thousands of dollars in drug and medical costs. Some patients will qualify for subsidies that will further lower that cap, depending on their income, and the cap applies to both medical and drug benefits.
Even so, Pearson said some patients may be asked to pay hundreds and, in some cases, even thousands of dollars at their first visit to a pharmacy once their plan goes into effect, a cost that could deny them needed treatments.
Damian Brayko, the operations manager at Cover Oregon, the state marketplace, said the out-of-pocket limit acted as a powerful safety net for patients with chronic illnesses. The health-care law, he said, “isn't a perfect piece of legislation, but I think it's taking steps in the right direction, and that's how we're looking at it.”
Pharmaceutical companies have traditionally offered assistance programs and coupon cards to help patients cover their out-of-pocket costs. But that is another question that has not been answered yet. The Health and Human Services department is still ruling on whether the state marketplaces could be considered a federal program. Drug companies are prohibited from providing direct assistance to recipients of Medicaid and Medicare because it is considered an illegal kickback. Nonprofit groups that are often financed by the drug industry provide assistance to those patients instead.
Many patient-advocacy groups are questioning why the Obama administration did not more closely adopt the features of Medicare's drug-benefits program, known as Part D, which got off to a rocky start in 2006 but is now seen as a successful program. One of the top features that advocates say they wish was in the marketplaces is something similar to Part D's Plan Finder, which suggests plans based on the drugs that recipients take.