With the Texas high-risk pool set to close early next year, Earley, who works on contract as an architect in Arlington, is checking into plans on the health insurance marketplace. The plan with the best Humira coverage—a $150 copay per refill—is a gold plan with a $1,718 monthly premium for the two of them, says Earley. Plans with lower premiums would require 40 to 50 percent coinsurance for the drug, which is in a high-cost specialty tier.
“What I’m finding with the insurance policies that are available, it’s going to cost you either way,” says Earley.
The gold plan with the best Humira coverage would cost roughly a quarter of their income, says Earley, who is not eligible for tax credits to subsidize his premium costs. But that may be their best option, even with financial assistance from the drug's manufacturer, given the high drug coinsurance charges on the other plans.
Drug costs are perhaps the most often cited coverage concern for people with chronic conditions, but there are others, say experts.
Access to specialists and to academic medical centers with the necessary expertise can be problematic on the marketplaces, where many insurers have opted for a narrow network of doctors and hospitals in order to keep a lid on premiums. A recent McKinsey & Co. study found that 70 percent of the 120 plans it examined offered narrow hospital networks that excluded at least 30 percent of an area’s biggest hospitals. Academic medical centers were generally part of broader plans whose premiums were 10 percent higher than average.
For people who need specialist care, narrow networks can be problematic since the law’s limits on what a patient spends out-of-pocket only apply to in-network care. Dermatologists trained in handling severe psoriasis may not be in network, nor the academic medical centers that some people need for treatment, says Leah Howard, director of government relations and advocacy at the National Psoriasis Foundation.
On the other end of the spectrum, sometimes the out-of-pocket costs for effective treatments such as phototherapy can deter patients who would have to make a copayment for perhaps dozens of sessions.
Tue, Dec 24 2013