Drugmakers: Can we legally help QHP patients?

In the past, federal law imposed no limits on commercial coverage out-of-pocket costs.

In practice, some individual policies set deductibles as high as $10,000 or $20,000 per year, but most group plans and many individual policies held annual out-of-pocket maximums to much lower levels.

PPACA does offer low-income and moderately low-income QHP users help with paying out-of-pocket costs, but only for enrollees with incomes under 250 percent of the federal poverty limit.

High co-pays for costly drugs may be more common for QHP enrollees than for ordinary commercial coverage enrollees.

To keep the cost of premiums low, 90 percent of the QHPs  feature "specialty tiers" that may require patients to pay a percentage of the cost of the most expensive drugs — from 20 percent to 50 percent — instead of a fixed co-pay of $20 or $50, according to Avalere Health L.L.C.

For a middle-income family, spending $12,700 out-of-pocket on drugs and other health care products and services would be a struggle, according to Davenport-Ennis, whose Washington-based nonprofit connects patients with assistance that can help offset the costs of their care.

"If you look at the household incomes people going into the exchange marketplaces have, I can't imagine they're going to be able to afford this," she said.

Personal crisis

For Jeffrey Brandt, 60, paying the cost of his medicines without assistance would push his family into a financial crisis, according to his daughter, Tricia.

Brandt is in many ways the ideal Obamacare beneficiary. The Dallas man bought a "gold" plan on Texas's insurance marketplace and in January was diagnosed with advanced colon cancer for which he's now covered.

Yet he also faces $900 in weekly co-pays for the chemotherapy drugs he'll take for seven months.

He may get financial help from Amgen and Roche Holding AG, makers of two of the more than dozen drugs prescribed to fight his cancer. Roche's Avastin, for example, can cost from $45,000 to $109,000 for a course of treatment, according to the company.

Under his Blue Cross Blue Shield of Texas "gold" plan — the second-highest coverage level under Obamacare – Brandt must spend $3,250 out of pocket before the plan covers his co- payments, on top of what his daughter says is a $500 monthly premium.

Louis Adams, a spokesman for the insurer, didn't comment on the issue when reached by e-mail yesterday.

In the past, Brandt made about $50,000 a year, according to Tricia Brandt, who is managing his care. He had to stop work as a construction contractor while being treated for his cancer, and he is using his savings to pay his premiums and the drug co- pays.

"He just started chemo," Tricia Brandt said. "I've had to help pay for all of his prescriptions because he doesn't have an income right now."

Brandt's co-payments are about as much as his daughter's weekly income from the 70 hours a week she works as an accountant. She said she'll move into a smaller apartment in two weeks to cut her expenses to help fund his care.

"I started cleaning houses on nights and weekends," she said. "I don't know else to do."

When Tricia Brandt has time between jobs, she fills out assistance applications to drugmakers, hoping that help for her father comes through. Even if they get that help, it could be cut off if the government decides that such co-payment programs are illegal.

Tricia Brandt said she is hopeful for her father. "As long as we can keep his treatment steady, he'll knock it," she said. "I told him, 'You concentrate on getting better, I'll concentrate on taking care of the cost.'"

See also:

• Exchange plans skimp on blood cancer coverage
• Drug fees surge under PPACA, report says
• So much for PPACA effectiveness research