Drug-Cost Surprises Lurk Inside New Health Plans

Americans with chronic illnesses—who are expected to be among the biggest beneficiaries of the health law—face widely varying out-of-pocket drug costs that could be obscured on the new insurance exchanges.

Under the law, patients can’t be denied coverage due to existing conditions or charged higher rates than healthier peers. The law also sets an annual out-of-pocket maximum of up to $6,350 for individuals and $12,700 for families, after which insurers pay the full tab.

But depending on the coverage they select, some patients on expensive drug regimens could reach that level fast. Some medications for conditions including hepatitis, rheumatoid arthritis, HIV and cancer can retail for thousands of dollars a month, and some plans require patients to pay as much as 50% of the cost.

The HIV drug Atripla, for example, typically retails for about $2,200 a month. On “silver,” or midlevel, plans in Miami-Dade County, Fla., with comparable premiums, monthly out-of-pocket costs for Atripla range from $55 on Molina Marketplace Silver to $902 on Cigna Corp.’s Health Flex 1500. On a single Cigna plan, Health Savings 3400, out-of-pocket costs for Atripla vary from zero if patients buy from an in-network pharmacy to $1,127 if they don’t.

A spokeswoman for Cigna said the insurer offers several plan choices so patients can select one that best meets their needs and budget. A spokesman for Humana said the out-of-pocket maximums on exchange plans protected patients from excess costs. A representative from Molina didn’t respond to requests for comment.

In general, the lower a plan’s monthly premium, the higher the portion of drug costs patients must bear. But an array of other factors also affect cost to patients—including whether a medication is on the insurer’s covered-drug list, or formulary; in what level, or tier, of coverage it is; and what cost-sharing formula applies to that tier, which can vary from plan to plan even among those offered by the same insurer in the same bronze, silver or other category.

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