Impatient | Helping make the health care system work for you

Will my health plan cover my drugs? Right now, it's hard to tell

Sacramento bike advocate Charis Hill has a rare form of arthritis that can only be managed by remaining active - and taking special medication.
Sacramento bike advocate Charis Hill has a rare form of arthritis that can only be managed by remaining active - and taking special medication.
Courtesy of Glenn Jones/Ikona Photography

Charis Hill is a Sacramento bike advocate. On her blog, she writes that she bikes because she has "no desire to contribute to poor health, environmental damage and the fast-paced life."

She also bikes because she has a rare form of arthritis called Ankylosing Spondylitis. She says her spine is fusing together from the bottom up, and the intense pain can only be managed by remaining active - and taking a special medication.

But what happens when that medication becomes unaffordable?

Hill began shopping for a health insurance plan through Covered California last year, because her old plan didn’t comply with the provisions of the Affordable Care Act. But, she recalls, she stalled because there was no way to determine how much her medication – a weekly shot called Enbrel – would cost under different plans.

"I was confused and frustrated and missed the deadline to apply before the end of the year," she says.

She was bumped into a default plan. When she tried to refill her prescription with her new insurance, she says, her monthly prescription no longer cost $5.

It suddenly cost a prohibitive $2,000.

She returned to the Covered California website to find a new plan. This time, she worked with a certified enrollment counselor and he, too, had no way of telling how much her medication might cost on various plans.

The fact that even an enrollment counselor could not access this critical information "doesn’t leave the consumer feeling confident in the system, or in their future with their healthcare," says Hill.

This is a widespread problem

Hill's problem is now fixed; she’s in a new plan, and her medication is now $10 each month. But many people with chronic health problems are facing the same predicament: They can’t easily determine which Covered California plans cover their drugs, and at what cost.

On Covered California, insurance plans generally list their most commonly prescribed drugs, says Alison Ramey, with the American Cancer Society’s Cancer Action Network. But to determine if a consumer’s specific drug is part of that formulary, they have to call individual plans, wait on hold, and sometimes get bounced to the company’s website.

For people who rely on a medication to save their life – or dramatically improve the quality of their life – knowing how much it costs under a specific health plan is as important as knowing whether a specific doctor is covered, Ramey says.

A state lawmaker offers a potential fix

Charis Hill recently testified in Sacramento support of Senate Bill 1052, which would require all health plans on Covered California to post their drug formulary, and the cost-sharing associated with each drug.

The bill, sponsored by State Senator Norma Torres, would allow people to shop for plans based on which drugs they take. It would require Covered California plans – and all other plans on the market – to include a search window, where people could type in their medication, and find out which plans would cover it, and at what cost.

The bill will next be heard in the Senate Appropriations committee.

Did you or someone you know have trouble determining how much your medication would cost under different insurance plans? Tell us about it in the comment section below.