You might wonder how the Affordable Care Act (ACA) will affect what you pay for your arthritis medicines. Here’s an overview of what you can expect.
Insurance Plans and Drug Tiers
Prescription drugs are now “an essential benefit” under the ACA. How much you pay will depend on your plan.
There are four tiers in an insurance plan formulary (or covered drug list):
• Tier 1 are the least expensive generic medicines
• Tier 2 are the insurance company’s preferred brand-name medicines
• Tier 3 are non-preferred brand-name medicines
• Tier 4 are specialty medicines
A Tier 1 drug might only cost you a $5 or $10 co-pay, but for a Tier 4 drug you’ll pay a percentage of the total drug price.
The Health Insurance Marketplace and Drug Coverage
The marketplace offers four types of plans - Bronze, Silver, Gold and Platinum.
With gold and platinum plans you’ll pay a higher monthly premium, but more of your prescription drug costs will be covered. Bronze and silver plans have more affordable premiums, but may cover less of your costs. When comparing plans, make sure that your medications are covered.
Will Your Arthritis Drug Costs Increase?
Under the ACA, insurance companies can no longer put lifetime caps on out-of-pocket expenses or exclude people with pre-existing conditions like arthritis. Some companies are trying to control costs – in part, by moving expensive drugs like biologics into Tier 4.
For a biologic, that could mean $6,000 annually out of pocket.
Medicare and Your Medications
The ACA will close the coverage gap known as the “donut hole,” which starts once you’ve spent $2,970 on your medicines. Now once you hit that gap, you’ll get a 50 percent discount on brand-name prescription drugs. The discount will continue to increase until it reaches 75 percent in 2020.
Biologics and Biosimilar Drugs
The ACA has now paved the way for the production of biosimilars – drugs that act in a similar way to biologics. These drugs should be less expensive than biologics, although they may not be dramatically cheaper, according to Timothy J. Laing, MD, associate chair of clinical programs at the University of Michigan Department of Internal Medicine. However, it’s also important to understand that biosimilars and biologic aren’t exactly the same.