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High Premiums Don't Bring Better Specialty Drug Coverage

Analysis  |  By Gregory A. Freeman  
   June 25, 2018

Expensive drugs often are not covered by even the plans offering the best benefits in return for higher premiums.

The highest monthly premiums in Medicare Part D and Medicare Advantage plans do not always guarantee better coverage for specialty drugs, according to recent research.

The study from HealthPocket, a website that compares and ranks all health insurance plans, looked at the challenges facing beneficiaries in 2018 Medicare Part D and Medicare Advantage plans when trying to find the most extensive specialty drug coverage.

Coverage for specialty drugs is particularly important for some consumers because the medications can cost thousands of dollars per month if obtained out-of-pocket. Medicare drug plans can reduce those costs if the specialty drug is on formulary and but they often are not.

Medicare beneficiaries in this situation can petition a plan for a formulary exception, but the request can be denied. If they want to find a new health plan that covers the specialty drug, they usually must wait for the next enrollment period.

These are other findings from the research:

  • The average Medicare Advantage plan had more specialty drugs (635) listed on its formulary than the average Part D plan (531).
  • However, the insurance plan with the largest coverage of specialty drugs in 2018 was a Medicare Part D plan, Educators Rx Advantage (PDP) offered in Utah and Idaho, with 952 specialty medications covered.
  • The plans with the fewest specialty drugs listed in their formularies (301) came from the Medicare Advantage category.
  • Paying the highest monthly premium did not obtain the broadest specialty drug coverage. (Health plans do not claim that it does.)
  • Blue Cross MedicareRx Plus (PDP) offered in Texas had the highest monthly Part D premium of $197.10 but only covered 642 specialty drugs as compared to the 952 specialty drugs in the plan with the broadest coverage.
  • Among traditional Medicare Advantage plans, Medicare Plus Blue PPO Assure (PPO) from Blue Cross Blue Shield of Michigan had the highest monthly premium at $312.50 and covered 609 specialty drugs.
  • A "Cost Plan" version of Medicare Advantage, HealthPartners Freedom Ultimate with Enhanced Rx (Cost), in Minnesota had an even higher monthly premium at $375.90 and listed 680 covered specialty drugs.
  • The average 5-star Part D plan covered 495 specialty drugs, which is fewer than the 531 average for Part D plans as a whole. 5-star Medicare Advantage plans fared better than 5-star Part D plans.
  • On average, 5-star Medicare Advantage plans covered 606 specialty drugs, fewer than Medicare Advantage plans as a whole (635) but more than the average for 5-star Part D plans (495).

HealthPocket recommends that Medicare insurance comparison websites present the number of covered drugs and the number of covered specialty drugs for each Medicare drug plan.

Gregory A. Freeman is a contributing writer for HealthLeaders.

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