Good news for patients: Platinum health plans are a better deal for specialty drugs

Among the various 'metal' health plans, coverage increases as premiums go up, says HealthPocket.com

It wouldn’t be unexpected: higher-premium plans should have better coverage of more or higher-cost medical services, but it’s nice to see that confirmed by a study by HealthPocket.com, a two-year-old consumer-health service that allows comparison shopping of plans. Its just-released study finds that across five commonly prescribed specialty products (Humira, Copaxone, Gleevec, Atripla, and Norditropin used to treat inflammation, multiple sclerosis, cancer, HIV, and growth deficiency respectively), out-of-pocket (OOP) costs for patients on platinum plans were 64% lower than gold plans, 74% lower than silver plans, and 78% lower than bronze plans. Data are based on announced 2015 plans, and results vary by age.

Specialty drugs are an increasingly noisy battleground between payers and the pharma industry, notably with the controversy over the high price being charged by Gilead Science for Sovaldi, its hepatitis C treatment. But Sovaldi isn’t the highest-priced specialty drug (by a long shot); the controversy swirls around it mostly over the several million potential patients for the drug, and the actions taken by PBMs and payers to control annual expenditures for the drug.

Nearly all plans have some OOP component; but the premium plans have a lower OOP limit, which typically is exceeded by the annual cost of many specialty products. For a 50-year-old consumer taking the cancer drug Gleevec, says HealthPocket, bronze plans incurred costs of approximately $11,400 on average, including both annual out-of-pocket costs and premiums. Platinum plans incurred an average total cost of about $9,700, even though their premiums were over $3,000 more expensive for the whole year than bronze plan premiums. For a 30-year-old taking Gleevec, platinum plans were also on average the cheapest option overall. The 30-year-old’s average total costs for platinum plans were 21% lower than gold plans, 29% lower than silver plans, and 30% lower than bronze plans.

Cost data were based on CVS Pharmacy price quotes and standard adult dosages from goodrx.com.