Tags: drugs | obamacare | insurers | loophole | formulary

Obamacare Drug Plans Will be More Costly for Chronically Ill

Image: Obamacare Drug Plans Will be More Costly for Chronically Ill

By Melissa Clyne   |   Tuesday, 10 Dec 2013 08:04 AM

The list of Obamacare problems keeps growing, this time with news that many insurance plans being offered provide  inadequate drug coverage for people with expensive or chronic conditions.

By either not providing coverage for certain drugs or requiring patients to pay huge co-pays — up to 50 percent in some cases — many insurers participating in the Obamacare exchanges are in essence pricing people out of treatment, The Washington Post reports.

So while the president touts his signature plan for covering everyone, regardless of their condition, treating that condition could be extremely costly for many chronically ill Americans.

Editor's Note: ObamaCare Is Here. Are You Prepared?

Typically, a plan limits out-of-pocket expenses for its insured, but a loophole in Obamacare is that only drugs listed on a plan’s formulary are included, according to Forbes.

If a particular drug is not listed on the formulary — and many are not — the patient is responsible for its full cost. Additionally, the cost won’t count against deductibles or out-of-pocket limits, $12,700 for a family, $6,350 for an individual.

Patients with diseases like cancer, AIDS, multiple sclerosis, rheumatoid arthritis, and autoimmune diseases are all vulnerable.

While technically these patients will have health insurance, using it may be cost prohibitive because some insurance plans have been structured to penalize the chronically ill, according to some healthcare advocates.

“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,” Marc Boutin, executive vice president of the National Health Council, told the Post.

But the insurance industry insists that the plans meet or exceed minimum requirements under Obamacare and in order to offer low premiums, carriers must restrict the cost of some expensive drugs. When there are no alternate drugs available, the Post reported that insurers believe "it’s reasonable to expect patients to pick up more of the cost.”

Robert Zirkelbach, a spokesman for American’s Health Insurance Plans, told the Post that the plans being offered under Obamacare are designed “to try to give consumers better value for their healthcare dollars.”

Joanne Peters, a spokeswoman for the Department of Health and Human Services, also told the Post that the plans under Obamacare will give many patients access to drugs they couldn't get before and that exceptions can be made by insurers if more expensive medicines are needed. Insurers are required to respond to such requests within three days.

But insurers are also doing things like limiting quantities of certain drugs and requiring “fail first” protocols that force doctors to try certain drugs first before asking for others, regardless of whether the doctor’s knowledge and experience dictate otherwise. That's a big concern to doctors who treat the chronically ill.

“2014 is going to be a very scary year," Dr. Daniel Kantor, a Florida neurologist, told the Post. “People are going to have to stop taking medicines they are already stable on because of this."

Kantor, who treats patients with multiple sclerosis, added that insurers "are hoping that if they make it inconvenient for people with MS to get treatment, they will leave their rolls.”

Editor's Note: ObamaCare Is Here. Are You Prepared?

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