Prescription Drug Coverage Comparison of Individual Healthcare.gov Plans

- Kevin.Kane@citizenactionwi.org

This report seeks to compare what consumers across Wisconsin pay for prescription drugs region to region. The price of drugs tend not to vary much city to city, however what cost consumers actually see depends on the health insurance plans being sold in the region. 

Key Facts

  • Prescription drug deductibles range from $400 to $2,500 depending on the metro.
  • Average out-of-pocket maximums have gone up 7.9% statewide since last year.
  • What consumers pay for one month of the expensive drug “Pomalyst” with the most common insurance plan ranges from $453 in Madison to $5,375 in La Crosse.

 

This report looks at four indicators to highlight geographic variations in the impact of high drug costs.

    1. Average deductible of all silver plans within the metropolitan area’s major county (ex: Appleton is Outagamie County)
    2. Average out of pocket maximums of all silver plans within the metropolitan area’s major county
    3. Percent increase in average prescription drug deductibles and out-of-pocket maximums in counties from previous year.
    4. A test of a high priced drug to show what a consumer is most likely to see in actual costs.

We specifically look at Silver plans, as they are the most common plan purchased on Healthcare.gov. We do not include the tax credits that consumers under 400% of the federal poverty line may be eligible for if they choose a silver plan. The reason for that is to show the clear price that prescription drug costs cost, either for those ineligible for tax credits or for both the consumer and federal government together.

Prescription drug deductibles are often a separate number for insurance plans than medical deductibles, although not always. Thus reports showing only medical deductibles will look different than this report.

Table 1: Average prescription drug deductible by Metro, 2015. 


Table 2: Average Out of Pocket Maximum by City
 


Table 3a: Percent change in average deductible by City, 2014 to 2015
 

METRO

Deductible change

 

METRO

Deductible change

Waukesha

-32.82%

 

Milwaukee

+13.87%

Stevens Point

-32.61%

 

Racine

+13.87%

Eau Claire

-25.00%

 

Superior

+15.00%

Rhinelander

-22.60%

 

Appleton

+15.04%

Fond du Lac

-6.59%

 

Hudson

+36.46%

Wausau

-4.31%

 

La Crosse

+37.63%

Green Bay

+4.74%

 

Madison

+42.86%

Manitowoc

+4.74%

 

Oshkosh

+70.71%

Sheboygan

+4.74%

 

Wis Rapids

+73.87%

Kenosha

+7.24%

 

Janesville

       *

   

 

STATEWIDE

-4.51%

Note: Janesville’s average deductible increased from $0 in 2014 to $454 in 2015, we cannot show a percent increase

 

Table 3b: Percent change in average out-of-pocket maximums by City, 2014 to 2015


  

Our final test looked at what a consumer would see with a very expensive drug. We chose Pomalyst, a cancer drug for multiple myeloma that costs $10,500 for a 30 day supply1. Pomalyst is considered a “specialty” drug2. While previous tests looked at average deductibles, the consumer does not pay that “average” amount. Instead we chose the most common plan (2nd lowest cost silver) and show what that 30 day supply and one month of premiums would equal by city.

Table 4: Test with expensive drug, 2nd lowest cost silver plan for a 40 year old resident by metro plus one month of premium.


* - Note, in only 4 metros – Wisconsin Rapids/Marshfield, Stevens Point, Waukesha and Fond du Lac – would a consumer hit their out-of-pocket maximum for the year in this 30 day expensive drug test.
 

Source: 2nd lowest cost Healthcare.gov silver plan by county for 40 year old applicant. Expensive drug test looks at one month premium, deductible, co-pays/co-insurance and out of pocket maximum for that plan.

 

 

1 – Newsweek (July 23, 2015) The High Cost of Cancer Care: Your Money or Your Life? http://www.newsweek.com/2015/07/31/high-cost-cancer-care-your-money-or-your-life-356369.html

2 – Anthem BlueCross BlueShield Specialty drug list https://www.anthem.com/health-insurance/nsecurepdf/pharmacy_NatlAccts_Specialty_DL

http://s18.postimg.org/nvaoqfnd5/pomalyst_chart.png

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