Consumers could pay more for specialty drugs with marketplace health plans

McClatchy Washington BureauFebruary 20, 2014 

Rather than paying a fixed-dollar co-payment for specialty medications that treat rare and serious diseases, most marketplace insurance plans require consumers to pay a percentage of the actual cost, known as coinsurance.

This payment option could cause patients to incur several thousand dollars of cost-sharing before they their out-of-pocket maximum, according to a new analysis by Avalere Health, a DC health consulting firm.

The research found that 59 percent of marketplace Silver plans use this payment system for specialty drugs compared to only 38 percent of more expensive Platinum plans.    
"Health plans operating in the exchanges are using significant cost-sharing to meet actuarial values set forth in the law and to limit premium costs. However, these formulary designs often result in high costs for patients with chronic illness who need biologics" and other specialty drugs, said Dan Mendelson, CEO and founder of Avalere Health.
 To read the analysis, go to

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