Even though health insurance plans have been greatly simplified with the introduction of the metal tiers of Bronze, Silver, Gold and Platinum under the ACA, careful consideration should still be given when comparing the coverage and benefits. In particular, for many people that have recurring brand name prescriptions medications, selecting the least expensive Bronze plan may end up costing more at the end of the year.
Cheaper Bronze premium with less Rx
The Bronze plan, through Covered California, has an average annual deductible of $5,000 which includes both the medical and pharmacy benefit. In other words, subscribers of the Bronze plan must accumulate $5,000 in deductible expenses before there is any copayment for brand name drugs of $50. This inclusive deductible provides no relief for individuals that are on expensive maintenance prescription medications until they hit $5,000.
Silver plan may be gold for saving money
The Silver plan, by comparison, has medical deductible of $2,000 and a pharmacy deductible of $250 (excluding any enhanced Silver plans which have reduced deductibles at lower income ranges). Once an individual’s prescriptions drug costs equals $250, they then receive the benefit of a $50 copayment for brand name drugs. This could be a significant savings for prescription medications over the year even with the higher premium of the Silver plan.
Annual prescription cost comparison
This comparison is based on a 40 year old in Sacramento County. The plans are the least expensive Bronze and Silver in the region.
| Bronze | Silver | ||
| Monthly Premium | $250 | $335 | |
| Yearly Premium Total | $3,000 | $4,020 | |
| Prescription Medications: | $300 | $300 | January* |
| Two Brand name drugs at $150 | $300 | $100 | February |
| per prescription per month = $300 | $300 | $100 | March |
| $300 | $100 | April | |
| $300 | $100 | May | |
| $300 | $100 | June | |
| $300 | $100 | July | |
| $300 | $100 | August | |
| $300 | $100 | September | |
| $300 | $100 | October | |
| $300 | $100 | November | |
| $300 | $100 | December | |
| Total prescription drug costs/year | $3,600 | $1,400 | |
| Premium + Prescriptions | $6,600 | $5,420 | |
| Savings | $1,180 | ||
| *Silver plan pharmacy deductible | |||
| activates at $250. Brand name drugs | |||
| copayment = $50 | |||
Most health plans will have at least a 4 Tier drug formulary
- Tier 1 Generics
- Tier 2 Brand name
- Tier 3 Non-preferred brand name
- Tier 4 Specialty drugs
Research and compare prescription costs and copays
Because prescription drugs can a high percentage of the overall health care expenses for the year, it would be great if the state exchanges like Covered California could develop a pharmacy benefit calculator. Such a calculator would help guide people to the best drug formulary for their needs with the estimated copayments based on the consumer’s drug list. Perhaps that will be incorporated next year. Either way, it will pay dividends to do a little extra research on the pharmacy benefits of each health plan and compare them to the different metal level tiers.
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