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Under Obamacare Drug Coverage For Pre-Existing Conditions Could Be Costly

Obama with Gerald Seib of Wall Street Journal

Obama with Gerald Seib of Wall Street Journal

The Affordable Care Act (ACA) was designed to “provide Americans with better health security by putting in place comprehensive health insurance reforms,” according to the government website

The following list from the website, mentions certain key provisions that President Obama campaigned for the last few years including (but not limited to):

• Expanding coverage

• Lowering healthcare costs

• Covering pre-existing Conditions

However, with its botched debut in October and numerous insurance plans being canceled, it seems that there is still another issue with this legislation.

Pre-Existing Conditions Can Still Be Expensive

The ACA requires that insurance companies sell policies to anyone who wants one, without being charged a higher premium based on a pre-existing condition. This also means that the insurance companies are now required to take on more risks.

Thus, someone with breast cancer, heart disease, or even acne shouldn’t have to go without coverage or pay a substantially higher premium.

Except, if you’re taking medication for your pre-existing condition.

Americans with a pre-existing condition, like HIV/AIDS may not be able to afford their medications in 2014. Under some policies in the insurance exchanges, some common prescriptions for the disease are not covered and others require a much higher out-of-pocket spending than for other drugs.

The exchange system also makes it easy to compare costs of premiums but not the costs for medications. Thus, a buyer will have to do some research to find out if their meds will be covered and at what cost.

Insurance companies organize medications into “tiers,” and each tier has a different level of cost-sharing. A lowest tier may be free to the patient, while the higher tier requires fixed copay or a percentage paid. HIV/AIDS meds are usually in a higher tier.

“We’re making sure that formularies are robust, and [insurance companies] are not utilizing management techniques—like tiering or prior approval—that create unfair or undue burdens on people to meet their standard of care,” says Robert Greenwald, director of the Center of Health Law and Policy Innovation at Harvard Law School, and a co-chair of HIV Health Care Access Working Group.

The fear is that more insurance companies will place expensive medications at the higher tiers to offset the risk of covering less than healthy people.

“Of the six health plans offered through Illinois’ Obamacare insurance exchange, for example, just two offer accompanying prescription drug coverage that allow HIV patients to obtain prescription medications with copays of $50 or less,” according to says John Peller, vice president of policy at the AIDS Foundation of Chicago. But for more expensive HIV medications, some policies require a percentage paid, some as high as 50 percent. This could equally be thousands of dollars.

With higher drug costs (but not premium costs) this could still leave out the very Americans that the president promised his plan would insure. Obama was able to make small victories: since 2010 the “doughnut hole” or coverage gap  in Medicare prescription drug plans, has been shrinking, so seniors won’t have to choose between meds or food. But for the younger, sick, and poor Americans relying on the ACA exchange; will they fall through this doughnut hole?

S.C. Rhyne is a blogger and novelist in New York City. Follow the author on twitter @ReporterandGirl or Check out her website at


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