Are you among the tens of thousands of Americans who have seen the costs of some of their drug prescriptions shoot up despite having health insurance? You may be caught up in the so-called “Tier 4” pricing policy.
Previously, insurance companies typically had a three level pricing policy for drugs with co-pays ranging from $10 to $50 per prescription. On Tier 1 were generic drugs. Tier 2 was for name brand drugs and some generic drugs approved by the insurance provider. A third level included brand names drugs not approved by the provider, with higher co-pays. Recently, many health insurance companies began a fourth level of pricing, in which patients are required to pay 20%-33% of a drugs cost. This means a drug that once required a small co-pay could now cost patients hundreds of dollars a month.
Just to give a real life example, according to an article in the New York Times, a 53-year-old woman who is a multiple sclerosis patient, had been paying the traditional $20.00 co-pay for nearly twenty years for Copaxone, a specialty drug. This all changed when she recently went to the pharmacy and was billed an alarming $325.00 for her prescription. The annual cost for her prescription will now be near $3,900.
The problem is the idea that health insurance is designed to spread the burden of costs across a wider community. But in this case, those who are sickest will have to pick up more and more of the burden for themselves. However, insurance companies are breaking no laws of regulations with the introduction of “Tier 4” pricing. In fact, they have made the pricing changes at least in part to hold down rising premium payments.
But if the new pricing is legal, what can be done to help patients who need these “Tier 4” drugs to manage long-term illnesses? First, patients should also look closely at their health plans and, where possible, look for other insurance options if they are hit by “tier 4” pricing for medications they need. However, for many, options to their current plans are limited or do not exist.
If finding a better plan is not an option, patients should talk with their doctors and insurance company to identify other medications that have less costly co-pays and still provide the same medical benefits.
Critics of tier 4 pricing say society in general needs to encourage the production of generic drugs to compete with the brand-name “Tier 4” medications. In addition, we need to create a national system that will compare new specialty drugs with treatment options that are already running and cost less. If we don’t do something, “Tier 5” may soon become a reality.
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International Herald Tribune Opinion
