Obamacare’s Out-of-Pocket Costs for Specialty Drugs Increases 16% in One Year

Out-of-pocket costs for Humira pen totals $1,889.66 in 2017


Out-of-pocket costs for specialty drugs under the Affordable Care Act increased 16 percent from 2016 to 2017, according to a report from HealthPocket.

While prescription drug coverage comes standard with Obamacare plans, not all medications prescribed to individuals will be paid for.

"For a plan to help pay for a drug, the drug must first be included on the health plan's formulary," the report states. "Drugs that are off-formulary are not only paid for completely out-of-pocket by the enrollee but those expenses do not count towards the annual cap on out-of-pocket spending."

The report found that for Obamacare's silver plan, a Humira Pen, a specialty drug that treats arthritis and Crohn's disease, will total $1,889.66 in out-of-pocket costs, which increased $262.45 in price since 2016. Harvoni, a specialty drug used to treat those with hepatitis C, will total $12,590.60 in out-of-pocket costs, which increased by $1,762.59 in one year.

"Compared to the coinsurance rate for 2016, average cost-sharing for specialty drugs on silver plans rose 16 percent in 2017," the report states. "This increase in monthly out-of-pocket costs for the top five specialty drugs ranged from $226.29 to $1,762.59. The average cap on yearly out-of-pocket costs on 2017 silver plans is $6,449 for an individual and $12,952 for families."

In addition, copayments are high for specialty drugs for those with silver plans. The report found that the average copayment for specialty drugs was $261.55.

"Recent political debate on continuing $7 billion in annual cost-sharing subsidies largely ignored other substantial issues regarding Affordable Care Act out-of-pocket expenses," the report states. "Aside from matters such as deductibles faced by unsubsidized enrollees, there are also enduring concerns regarding out-of-pocket costs for prescription medications."

According to the head of research at HealthPocket, if individuals are taking these types of specialty drugs they should be considering high out-of-pocket costs.

"As out-of-pocket costs for specialty drugs continue to be a problem without resolution, consumers taking these medications need to be vigilant in their insurance shopping," says Kev Coleman, head of research and data at the company. "For these consumers, cost-sharing for specialty drugs and annual caps on out-of-pocket expenses can be even more important factors than premiums when financially comparing health plans."

Ali Meyer

Ali Meyer   Email Ali | Full Bio | RSS
Ali Meyer is a staff writer with the Washington Free Beacon covering economic issues that expose government waste, fraud, and abuse. Prior to the Free Beacon, she was a multimedia reporter with CNSNews.com where her work appeared on outlets such as Drudge Report and Fox News. She also interned with the Heritage Foundation and Pacific Research Institute. Her Twitter handle is @DJAliMeyer, and her email address is meyer@freebeacon.com.

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